Application For License Renewal - Salt Lake City printable pdf download

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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.