Fillable Commonwealth of Massachusetts Board of Registration in Veterinary Medicine Request for License Reinstatement

Fill Online, Printable, Fillable, Blank Commonwealth of Massachusetts Board of Registration in Veterinary Medicine Request for License Reinstatement Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Commonwealth of Massachusetts Board of Registration in Veterinary Medicine Request for License Reinstatement

On average this form takes 14 minutes to complete

The Commonwealth of Massachusetts Board of Registration in Veterinary Medicine Request for License Reinstatement form is 5 pages long and contains:

  • 1 signature
  • 8 check-boxes
  • 47 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Commonwealth of Massachusetts
Division of Professional Licensure
BOARD OF REGISTRATION IN VETERINARY MEDICINE
1000 Washington Street Suite 710 Boston Massachusetts 02118
REQUEST FOR LICENSE REINSTATEMENT
This form should only be used by former licensees seeking to reinstate a license which has been expired
for more than one (1) license cycle. A licensee whose license has been expired for less than one (1)
license cycle is still eligible for renewal but must contact the Board to request a license renewal form.
INSTRUCTIONS
Pursuant to the Board’s regulations, 256 Code of Mass. Regs. § 3.05, former licensees seeking
reinstatement of an expired license are divided into two categories: (1) licensees whose licenses have
been expired for less than three license cycles; and (2) licensees whose licenses have been expired for
more than three license cycles. Please follow the instructions on the next page which apply to your
situation. If you are unsure of the expiration date of your license, please visit the Division of
Professional Licensure’s public “Check a License” database and search for your license by name or
license number.
All materials should be submitted to the Board at the following address:
Board of Registration in Veterinary Medicine
Attn: Reinstatement Applications
Division of Professional Licensure
1000 Washington Street, Suite 710
Boston, MA 02118-6100
Following a review of your materials, the Board will notify you if your request has been approved or if
you must take additional steps. Please be advised that pursuant to 256 Code of Mass. Regs. § 3.05, the
Board may request that the former licensee appear before the Board for a formal interview, and may also
request that the former licensee obtain a passing grade in a clinical competency examination, prior to
approving the reinstatement of a license.
Upon final approval, the Board will mail a reinstatement form and request payment of any outstanding
renewal fees. The reinstatement form should be signed and returned to the Board, with payment,
immediately. Please note that the reinstatement fee is payable by check or money order only and must be
made payable to the “Commonwealth of Massachusetts.”
***All questions regarding the licensee reinstatement process should be directed to
Board staff by calling 617-727-5899.***
Licenses Expired LESS Than Three (3) License Cycles
Please submit the following documents to the Board:
(1) A cover letter requesting reinstatement of your expired license. The letter must be signed and
contain your:
i. full name;
ii. license number;
iii. current mailing address; and
iv. list of all jurisdictions (e.g., states or countries) where you are or have been licensed in a
professional capacity and the capacity in which you are or were licensed (e.g.,
veterinarian, real estate agent).
(2) Proof of completion of either 15 continuing education credits if your license has been expired for
less than two years, or 30 continuing education credits if your license has been expired for more
than two years (but less than three years);
(3) A completed, signed, and notarized Criminal Offender Record Information (CORI)
Acknowledgment Form (available at the end of this application); and
(4) An official license verification or certification sent from each licensing jurisdiction where you are
or have been licensed in a professional capacity to the Board either through the mail or email to
vetmedboard@mass.gov.
Licenses Expired MORE Than Three (3) License Cycles
Please submit the following documents to the Board:
(1) A cover letter requesting reinstatement of your expired license. The letter must be signed and
contain your:
i. full name;
ii. license number;
iii. current mailing address;
iv. explanation of your activities during the time period your license was expired;
v. reasons for requesting reinstatement; and
vi. list of all jurisdictions (e.g., states or countries) where you are or have been licensed in a
professional capacity and the capacity in which you are or were licensed (e.g.,
veterinarian, real estate agent).
(2) Proof of completion of 45 continuing education credits;
(3) A completed, signed, and notarized Criminal Offender Record Information (CORI)
Acknowledgment Form (available at the end of this application);
(4) A completed, signed license reinstatement attestation form (available at the end of this
application);
(5) A completed Jurisprudence Examination. Please contact the Board to request a copy of the
examination; and
(6) An official license verification or certification sent from each licensing jurisdiction where you are
or have been licensed in a professional capacity to the Board either through the mail or email to
vetmedboard@mass.gov.
Commonwealth of Massachusetts
Division of Professional Licensure
BOARD OF REGISTRATION IN VETERINARY MEDICINE
1000 Washington Street Suite 710 Boston Massachusetts 02118
LICENSE REINSTATEMENT ATTESTATION FORM
***THIS FORM IS TO BE USED ONLY FOR LICENSE REINSTATEMENT REQUESTS WHERE A
LICENSE HAS BEEN EXPIRED FOR MORE THAN THREE (3) LICENSE CYCLES***
If you answer NO to any of the following questions (1-5), please attach a separate, written
explanation.
(1) I am in compliance with G.L. c. 62C, §§ 47A, 49A.
YES_____ NO_____
(2) I have completed all required continuing education requirements in compliance with
Board statutes and/or regulations.
YES_____ NO_____
(3) I have reported to the Board all discipline taken against any professional license issued
to me.
YES_____ NO_____
(4) I have reported to the Board all criminal convictions and/or guilty pleas.
YES_____ NO_____
(5) As required by G.L. c. 30A, §13A, I have reported my Social Security Number.
YES_____ NO_____
I state and attest, under the pains and penalties of perjury, that all statements contained in this form
are true and correct to the best of my knowledge and belief.
___________________________ ___________________________
Signature Date
Revised: 07/2017
click to sign
signature
click to edit
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified
prospective license applicants and current licensees.
As a license applicant or current licensee, I understand that a CORI check will be submitted for my
personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby
acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check
for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I
may withdraw this authorization at any time by providing the Division of Professional Licensure written
notice of my intent to withdraw consent to a CORI check.
FOR LICENSING PURPOSES ONLY:
The Division of Professional Licensure may conduct subsequent CORI checks within one year of the
date this Form was signed by me. If subsequent CORI checks are necessary, the Division of
Professional Licensure will provide me with written notice of the subsequent CORI checks.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided
on Page 2 of this Acknowledgement Form is true and accurate.
_________________________________ _________________________________
Signature Date
Please provide the name of the board of registration and license type for which you are applying or currently hold:
_________________________________ _________________________________
Board of Registration License Type
NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS
EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE
VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES
AT THE ADDRESS SET FORTH ABOVE.
Page 1 of 2
SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
________________________ _________________________ _______________________ ______
*Last Name *First Name Middle Name Suffix
___________________________________________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________ ____________________________
*Date of Birth Place of Birth
*Last Six Digits of Your Social Security Number: ______ - _____________
Sex: ______ Height: ____ ft. ____ in. Eye Color: ___________
Driver’s License or ID Number: ___________________ State of Issue: ________________________
Current and Former Addresses:
______ ____________________________________ ______________________ _____ ________
Number Name City/Town State Zip
______ ____________________________________ ______________________ _____ ________
Number Name City/Town State Zip
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the
above-referenced subject by reviewing the following form(s) of government-issued identification:
1
Passport State-issued driver’s license Military identification State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee (Please Print) Date
SECTION B: VERIFICATION BY NOTARY:
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
through satisfactory evidence of identification, which was the following:
1
Passport State-issued driver’s license Military identification State-issued identification card
to be the person whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public: Notary Commission Expires On:
1
If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
Page 2 of 2
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Commonwealth of Massachusetts Board of Registration in Veterinary Medicine Request for License Reinstatement

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document