Free 50020.FH11 - Indiana

APPLICATION FOR THE NORTH AMERICAN VETERINARY LICENSURE EXAMINATION (NAVLE)
State Form 50020 (R / 1-06) Approved by State Board of Accounts, 2006

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

* Your Social Security number is being requested per IC 4-1-8-1. The request is MANDATORY, and this application cannot be processed without it.

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER LICENSE ISSUE DATE (month, day, year)
DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY

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

PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS.
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Telephone number (daytime) State Date of birth (month, day, year) ZIP code Place of birth (city and state or country)

APPLICANT INFORMATION
Social Security number *

(
Email address

)

VETERINARY SCHOOL INFORMATION NAME OF SCHOOL LOCATION OF SCHOOL DATE / EXPECTED DATE OF GRADUATION

PROFESSIONAL EDUCATION IN VETERINARY MEDICINE NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED DEGREE GRANTED

EXAMINATION RECORD EXAMINATIONS TAKEN NATIONAL BOARD EXAMINATION (NBE) CLINICAL COMPETENCY EXAMINATION (CCT) NORTH AMERICAN VETERINARY LICENSING EXAMINATION (NAVLE) Have you sat for the NBE, CCT or the NAVLE examination in the State of Indiana or any other state prior to this application? If you are a graduate of a foreign college of veterinary medicine, are you currently enrolled in the Educational Commission for Foreign Veterinary Graduates (ECFVG) program? Have you completed step 2 (english examination) of the ECFVG program? Do you hold, or have you ever held a license, certificate, registration or permit to practice any regulated health occupation? YES YES YES YES NO NO NO NO DATE OF MOST RECENT EXAMINATION (month, day, year) WHERE TAKEN (STATE) HOW MANY TIMES HAVE YOU SAT FOR THIS EXAMINATION

(Continued on the reverse side)

LIST ALL PLACES YOU LIVED SINCE GRADUATION FROM VETERINARY SCHOOL GENERAL LOCATION DATES

LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM VETERINARY SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATES OF EMPLOYMENT

If your answer is 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 license or permit 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 you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice veterinary medicine 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, plead 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? 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 signed (month, day, year)

YES YES YES YES YES YES YES

NO NO NO NO NO NO NO

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 a license to practice veterinary medicine. 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 signed (month, day, year)

VETERINARY SCHOOL CERTIFICATION OF EXPECTED GRADUATION NAVLE CANDIDATE

To be completed by the Dean, Secretary, or Registrar and must include the school seal. I hereby certify that __________________________________________________, is currently enrolled and expected to graduate from
(Name of Applicant)

__________________________________________________ on ______________________.
(Name of School) Signature of Dean, Secretary or Registrar (Date of graduation) Date (month, day, year)

Candidates who have not graduated from veterinary school 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