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APPLICATION FOR LICENSE RENEWAL
P.O. Box 146741, Salt Lake City, Utah 84114-6741
INTERNET RENEWAL
LICENSE NUMBER
OCCUPATION / PROFESSION TITLE
RENEWAL FEE
EXPIRATION DATE
REINSTATEMENTS
ID NUMBER
Please fill in:
Please call DOPL for
Additional fees are required
Veterinarian
$73.00
9/30/2016
your Internet Renewal
after expiration. See reverse
ID Number
for details.
NAME AND ADDRESS OF RECORD
ADDRESS / PHONE CORRECTION
Address:
City:
State:
Zip:
Phone: (
)
-
Email:
This address will be used for all correspondence from DOPL. You may use a
business address or PO Box instead of a home address. If your address
changes, notify DOPL directly. Do not rely on a postal service forwarding
order. Submit changes at
Please print in your name and address of record.
QUALIFYING QUESTIONNAIRE
Answer “YES” or “NO” for each question. Do not leave any question blank.
Please note that false, misleading, or fraudulent answers may result in loss of licensure and/or criminal prosecution and are subject to random audit.
(For questions 1 - 4 below, motor vehicle offenses such as driving while impaired or intoxicated must be disclosed, but minor traffic offenses such as parking or speeding violations do not need to be
listed.)
1. Since the last renewal or issuance of this license have you pled guilty to, pled no contest to, been convicted of, made a plea in
Yes No
abeyance to, or entered into a deferred sentence with respect to any felony or misdemeanor in any jurisdiction?
2. Since the last renewal or issuance of this license have you been charged with or arrested for any felony or misdemeanor in any
Yes No
jurisdiction?
3. Since the last renewal or issuance of this license have you surrendered or had any disciplinary action taken against a license to
Yes No
practice in a regulated profession?
4. Are you currently under investigation or is any disciplinary, administrative, or criminal action pending against you now by any
Yes No
agency?
If you answered “YES” to question 1, 2, 3 or 4 above, see #1A on page two for instructions on additional requirements.
AFFIDAVIT / SIGNATURE
Read the following carefully. Sign below or follow the instructions as indicated.
I certify under penalty of perjury that I am a United States citizen or a qualified alien who is lawfully able to work in the United States.
I also certify that I have completed or will complete all renewal requirements, if applicable, including those specified below before the expiration or reinstatement of my
license. I understand that I may be subject to audit by DOPL of having met these requirements.
I further certify that I am the licensee described and identified in this application for license renewal / reinstatement. I am qualified in all respects for the renewal or
reinstatement of this license. To the best of my knowledge, the information contained in this application is complete and correct, and is free of fraud, misrepresentation, or
omission of material fact. I understand that this application will be classified as a public record and will be available for inspection by the public, except with regard to the
release of information which is classified as controlled, private, or protected under the Government Records Access and Management Act or restricted by other law.
I am a citizen of the United States and I have a valid US Driver License or US State ID.
State:
License/State ID Number:
I am a citizen of the United States currently living outside the United States and do not have a valid US Drivers License or US State ID. Please
attach a legible copy of your valid passport or other documentation to verify you are a legal citizen of the United States.
I am a non-citizen of the United States, who is lawfully present in the United States and I have a valid US Drivers License or US State ID.
State:
License/State ID Number:
I am a non-citizen of the United States, who is lawfully present in the United States and I do not have a valid US Drivers License or US State ID.
Please attach a legible copy of your current and valid government issued document showing evidence of authorization to work in the United
States.
I am a foreign national not physically present in the United States.
Social Security Number
_-_
-_
Signature:
Date:
/
/
(If unable to sign, see #1B on page 2 for instructions.)
Unlawful Conduct : Your license will automatically expire
RENEWAL REQUIREMENTS
Specific to your occupation / profession:
unless you renew i
t prior to its expiration date. If your
license expires, yo
u may not practice until a new license is
issued. Subsectio
n 58-1-501(1)(a) and Section 58-1-502,
In accordance with Subsection R156-28-304, during the past 2 years, you
U.C.A., make it u
nlawful and punishable as a criminal
must have completed 24 hours of qualified professional education directly
offense to practice
your occupation or profession beyond the
related to your professional practice. If you received your initial license
expiration of your
license.
during the current renewal cycle, you must only complete a pro-rata
amount of qualified professional education for the time you were actually
licensed. DO NOT submit documentation of your completed hours unless
you are audited and requested to do so.
For Division Use Only – Do Not Write in this Area