DVM TEMP PERMIT APPLICATION FILL 2023 (R)
GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH OFFICE OF PROFESSIONAL LICENSURE & HEALTH PLANNING TEMPORARY VETERINARY PERMIT REQUEST RELIEF VETERINARIAN - PLEASE TYPE (HANDWRITTEN APPLICATIONS ARE NOT ACCEPTED) DATE: MM/DD/YYYY SUFFIX LAST MIDDLE FIRST DOB: MM/DD/YYYY LAST 4 DIGITS OF SS# EMAIL ADDRESS CELL PHONE # MAILING ADDRESS CITY STATE ZIP CODE REQUESTING VI DVM: LICENSE #: DATE(S) REQUESTED: PURPOSE FOR REQUEST: EDUCATION/TRAINING VETERINARY SCHOOL GRADUATE ❑ YES ❑ NO GRADUATION YEAR DEGREE STATE/PROFESSIONAL CERTIFICATIONS STATE LICENSED LICENSE # LICENSE DATES STATE LICENSED LICENSE # LICENSE DATES LIABILITY CARRIER POLICY # START /END DATE OFFICE USE ONLY BACKGROUND INFORMATION HAVE YOU WORKED IN THE VI PREVIOUSLY? IF YES, WHEN AND FOR WHOM? DO YOU HAVE ANY CURRENT OR PENDING DISCIPLINARY ISSUES ON YOUR RECORD? ❑ YES ❑ NO IF YES, PLEASE EXPLAIN: HAVE YOU EVER UNDERGONE DISCIPLINARY HEARING? ❑YES ❑NO IF YES, PLEASE EXPLAIN: HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR? …
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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH OFFICE OF PROFESSIONAL LICENSURE & HEALTH PLANNING TEMPORARY VETERINARY PERMIT REQUEST RELIEF VETERINARIAN - PLEASE TYPE (HANDWRITTEN APPLICATIONS ARE NOT ACCEPTED) DATE: MM/DD/YYYY SUFFIX LAST MIDDLE FIRST DOB: MM/DD/YYYY LAST 4 DIGITS OF SS# EMAIL ADDRESS CELL PHONE # MAILING ADDRESS CITY STATE ZIP CODE REQUESTING VI DVM: LICENSE #: DATE(S) REQUESTED: PURPOSE FOR REQUEST: EDUCATION/TRAINING VETERINARY SCHOOL GRADUATE ❑ YES ❑ NO GRADUATION YEAR DEGREE STATE/PROFESSIONAL CERTIFICATIONS STATE LICENSED LICENSE # LICENSE DATES STATE LICENSED LICENSE # LICENSE DATES LIABILITY CARRIER POLICY # START /END DATE OFFICE USE ONLY BACKGROUND INFORMATION HAVE YOU WORKED IN THE VI PREVIOUSLY? IF YES, WHEN AND FOR WHOM? DO YOU HAVE ANY CURRENT OR PENDING DISCIPLINARY ISSUES ON YOUR RECORD? ❑ YES ❑ NO IF YES, PLEASE EXPLAIN: HAVE YOU EVER UNDERGONE DISCIPLINARY HEARING? ❑YES ❑NO IF YES, PLEASE EXPLAIN: HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR? ❑YES ❑NO IF YES, PLEASE EXPLAIN: I hereby affirm under the penalties of perjury that the statements made in this application are true, complete, and correct. I further wave, for process of this application, any confidentiality provisions concerning the information required to be provided to this application. __________________________________ ___________ ____________________________ __________ Applicant’s Signature Date Witness Signature Date _________________________________________ _____________ Requesting VI DVM Signature Date PLEASE BE SURE TO ATTACH: 1. LEGIBLE COPY OF GOVERNMENT ISSUED IDENTIFICATION. 2. COPY OF STATE LICENSE & VERIFICATION. 3. COPY OF INSURANCE. 4. COPY OF DIPLOMA. EMAIL TO: PLHPDOCUMENTS@DOH.VI.GOV Professional Licensure & Health Planning, VI Department of Health – P.O. Box 222995 Christiansted, VI 00822-2995 Telephone: 340-773-1561 Ext. 4431 STX OR 340-774-7477 Ext. 5694 STT