Free 49703.FH11 - Indiana

APPLICATION FOR REGISTRATION AS A VETERINARY TECHNICIAN
State Form 49703 (R / 2-06) Approved by State Board of Accounts, 2006

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INSTRUCTIONS: Please type or print and answer all questions.

INDIANA BOARD OF VETERINARY MEDICAL EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER REGISTRATION NUMBER REGISTRATION ISSUE DATE (month, day, year) LAW EXAMINATION DATE (month, day, year) LAW EXAMINATION SCORE

APPLICANT

Two (2) passport-quality photographs taken not earlier than eight (8) weeks prior to the date of application, dated and signed across the back in the applicants I certify that this is a true photograph of myself.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route number) City Date of birth (month, day, year) T elephone number State Place of birth (city and state or country) E-mail address ZIP code * Social Security number

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BASIS OF REGISTRATION (Please check one) EXAMINATION ENDORSEMENT OF EXAMINATION SCORES ENDORSEMENT (Has not taken and passed a veterinary technology examination administered by PES or AAVSB, but has taken state constructed examination.)
Name of school Location of school

Applying to take the veterinary technology examination offered by the American Association of Veterinary State Boards (AAVSB). Based upon passing the veterinary technology examination administered in another state offered by the Professional Examination Service (PES) or the American Association of Veterinary State Boards (AAVSB). Based upon for the five (5) years immediately preceding filing an application has been acting as a registered veterinary technician in a state, territory, or district of the United States having registration requirements which are substantially equivalent and otherwise meets the requirements of the statute.
Date of graduation (month, day, year)

VETERINARY TECHNOLOGY DEGREE GRANTED BY

EXAMINATION RECORD EXAMINATION TAKEN Examination administered by the American Association of Veterinary State Boards (AAVSB) Professional Examination Service (PES) State Constructed Examination Have you sat for the Veterinary Technician National Examination (VTNE) in Indiana prior to this application? Yes No DATE OF MOST RECENT EXAMINATION (month, day, year) STATE ADMINISTERED HOW MANY TIMES HAVE YOU SAT FOR THIS EXAMINATION?

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PRE-PROFESSIONAL EDUCATION IN VETERINARY TECHNOLOGY NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED DEGREE GRANTED

TYPE OF REGISTRATION

STATE

STATES REGISTERED NUMBER DATE ISSUED

EXPIRATION DATE

STATUS

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM YOUR VETERINARY TECHNOLOGY PROGRAM GENERAL LOCATION DATES

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM YOUR VETERINARY TECHNOLOGY PROGRAM NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATES OF EMPLOYMENT

If you answer "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details, include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a registration issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice as a veterinary technician or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been treated for drug or alcohol abuse? 5. Have you ever been convicted of, pled guilty or nolo contendre to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 6. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes Yes No No No No

Yes Yes Yes

No No No

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APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for registration as a veterinary technician. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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VETERINARY TECHNOLOGY PROGRAM CERTIFICATION OF EXPECTED GRADUATION
To be completed by the Dean, Secretary, or Registrar and must include the school seal.

I hereby certify that enrolled and expected to graduate from
(Date of graduation)

(Name of applicant) (Name of school)

, is currently on

.

Signature of Dean, Secretary or Registrar

Date (month, day, year)

Candidates who have not graduated from a veterinary technology program may submit the Certification of Expected Graduation form or an original letter from the dean with the school seal. Please forward this certification or letter to the following address:

SCHOOL SEAL

Indiana Board of Veterinary Medical Examiners Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected]

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VERIFICATION OF VETERINARY TECHNICIAN REGISTRATION
INSTRUCTIONS: Type or print the top portion of the verification and send a copy to each state where you hold or have held a registration. Request each state to complete and send directly to: Indiana Board of Veterinary Medical Examiners Professional Licensing Agency 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected]
Name (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) State E-mail address ZIP code Social Security number *

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I hereby authorize the State of
Signature

to furnish the Professional Licensing Agency with the information below.
Date (month, day, year)

TO BE COMPLETED BY THE STATE BOARD
Registration number Registration issued based upon: Date of issuance (month, day, year) Expiration date (month, day, year)

Examination
Type of examination:

Endorsement

Other
Date of examination(s) (month, day, year)

Examination provided by the American Association of Veterinary State Boards (AAVSB) Professional Examination Services (PES) State Constructed Examination (Attach subjects, scores and average) Has the registration been subject to any disciplinary action? (Please attach certified copies of any disciplinary action taken by your board.) FORM COMPLETED BY:
Name Title State Board Date (month, day, year)

Yes

No

PLEASE AFFIX BOARD SEAL

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