Board of veterinary medicine department of Health Professions



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COMMONWEALTH OF VIRGINIA


BOARD OF VETERINARY MEDICINE

Department of Health Professions


PERIMETER CENTER

9960 MAYLAND DR., SUITE 300

RICHMOND, VA 232333 (804) 367-4468 e-mail: terri.behr@dhp.virginia.gov
APPLICATION FOR REGISTRATION TO PRACTICE AS AN

EQUINE DENTAL TECHNICIAN

PLEASE INCLUDE $100 APPLICATION FEE
Answer each question fully, truthfully, and accurately. If the space for any answer is insufficient, complete your answer on a separate sheet, specify the question number to which it relates, sign and enclose with this application. Do not staple enclosures to this application form.
I hereby make application for registration to practice as an equine dental technician in the Commonwealth of Virginia in accordance with and subject to the regulations of the Board of Veterinary Medicine and the laws governing the practice of veterinary equine dentistry in Virginia.
1. NAME IN FULL (Print or Type)

Last


First

Middle/Maiden



Address (Present) – Street








City


State

Zip Code



E-Mail Address


Place of Birth




Date of Birth
Month: _____ Day:_____ Year _______


Social Security Number or DMV Number *
_______- ________ - _____________

Area Code and Telephone Number
________ - ________ - ____________



*In accordance with §54.1-116 of the Code of Virginia, you are required to submit your Social Security Number or your control number issued by the Virginia Department of Motor Vehicles. [In order to obtain a Virginia drivers license control number, it is necessary to appear in person at an office of the Department of Motor Vehicles in Virginia. A fee and disclosure of your Social Security Number will be required.]

Your Social Security Number or drivers license control number will be used by the Department of Health Professions for identification and will not be disclosed for other purposes except as provided by law. Federal and state law requires that this number be shared with other agencies for child support enforcement activities. If you fail to provide one or the other of these numbers, the processing of your application will be suspended and fees will not be refunded. No license, certificate or registration will be issued to any individual who has failed to disclose one of these numbers.


2. Required recommendation for registration:

Name of two veterinarians licensed in Virginia with practice bases that are at least 50 percent equine who have observed your practice in equine dentistry and can attest to your competency. Recommendation forms must be sent to the Board directly from the veterinarians.


(Name) _______________________________________ (Name)__________________________________
(Street)________________________________________ (Street)__________________________________
(City,State, Zip)_________________________________ (City, State, Zip)___________________________

APPLICANTS DO NOT USE THESE SPACES – FOR OFFICE USE ONLY

APPLICATION NUMBER

FEE

3. Qualifications for registration:
Regulations require documentation of one of the following qualifications for registration. Check the appropriate qualification box and provide the documentation as specified.
[ ] Current certification from the International Association of Equine Dentistry
Have the IAED send verification of current certification directly to the Board of

Veterinary Medicine

 

[ ] Completion of a board-approved certification program or training program


There are currently no certification programs or training programs approved by the Board. If you wish to apply under this qualification, you may request that the training program you attended provide a transcript of your coursework and a description of the program in equine dentistry for Board review.

 

[ ] Completion of a veterinary technician program that includes equine dentistry in the



Curriculum
Have your AVMA-accredited veterinary technician program provide a transcript of your

coursework in equine dentistry directly to the Board.

 

[ ] Evidence of equine dental practice for at least five years and proof of 16 hours of



continuing education in equine dentistry completed within the five years immediately preceding application for registration.
If applying under this qualification please complete professional experience section below:
Professional Experience. (Please provide evidence of equine dental practice for at least five years beginning with the most recent.)


Began


M/Y

Ended


M/Y

Name and Address of Business

Type of Activity

Status of Applicant

(Employee, Partner, Owner)


















































































and
Provide proof (certificate of completion) of sixteen (16) hours of continuing education in equine dentistry completed within the five years immediately preceding application for registration.
4. Have you ever been known by any other name? If so, state in full every other name [ ]Yes [ ] No

by which you have ever been known. If change was made by court order, enclose

a copy of order.

5. Have any charges or complaints relating to the practice of veterinary medicine, [ ] Yes [ ] No

veterinary technology, or equine dentistry, formal or informal ever been made

against you, or have any proceedings been instituted against you by a board of

veterinary medicine?

If the answer is yes, for each occurrence furnish a written statement giving the dates, the

nature of the charge, the disposition of the matter, and the name and address of the authority

in possession of the records thereof.


6. Have you, within the last two years, been treated by, consulted with, or been under [ ] Yes [ ] No

the care of a professional for substance abuse?


7. Have you, within the last two (2) years, received treatment for/or been hospitalized [ ] Yes [ ] No

for a nervous, emotional, or mental disorder which could impair your practice?

If yes, please provide a letter from the treating professional.
8. Have you ever been reprimanded, denied a license or registration, had your license [ ] Yes [ ] No

or registration suspended, cancelled or revoked by any board?


9. Do you have a mental or physical condition which could affect your performance of [ ] Yes [ ] No

professional duties, If yes, please provide a detailed explanation and a letter from the

treating professional.
10. Have you ever been convicted of a violation of/or pled Nolo Contendere to any [ ] Yes [ ] No

federal, state, or local statute, regulation, or ordinance, or entered into any plea

bargaining relating to a felony or misdemeanor? (Excluding traffic violations, except

convictions for driving under the influence) Please provide details.


11. Are you the spouse of a member of the U.S. military who has been transferred to [ ] Yes [ ] No

Virginia and who had to leave employment to accompany your spouse to Virginia?


12. In addition to the foregoing, I add the following:
(a) I have read and understand the Virginia Board of Veterinary Medicine statues and regulations and am aware that if granted a registration to practice as an equine dental technician in Virginia, I am required to comply with any laws and regulations governing the practice of equine dentistry
(b) I hereby give permission to the Virginia Board of Veterinary Medicine to obtain additional information relating to any statement in the application from any person or any source as the Board may desire.
(c) I shall present any credentials required or requested by the Board.
(d) I have attached a money order or check in the amount of $____________, made payable to the Treasurer of Virginia.
(e) I hereby certify that in applying to the Virginia Board of Veterinary Medicine for a registration to practice as an equine dental technician in Virginia, I have made no fraudulent statements, no omissions, nor have I misrepresented any material fact.

I have carefully read the statements and questions in the foregoing application and have answered them completely without reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for the denial, suspension or revocation of my registration to practice as an equine dental technician in the Commonwealth of Virginia.

____________________________________________________

Applicant's Signature


The City/County of _____________________ State of ____________________________.

Before me, the undersigned authority, on this day ___________________________________ personally appeared who after being duly sworn by me on his or her oath that all facts, statements and answers contained in this application are true and correct in every respect.


__________________________________________

Applicant’s Signature - Signed in presence of Notary

Sworn and subscribed to before me this _______ day of _________________________, ____, to certify which witness my and official seal of office.


My Commission expires:_________________________________

_________________________________________

Notary



EQUINE DENTAL TECHNICIAN (revised 06/2014


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