Veterinarian: Licensed Work Experience Verification

Public Health: Verification Of Licensed Work Experience As A Veterinarian

DPH Data Management and Governance (PLIS)
INSTRUCTIONS:
This form is to be used for verification of licensed work experience only if you meet all applicable requirements for Connecticut licensure by waiver of examination based on licensed practice. Please complete the upper portion of the form and forward the form to the individual who will be verifying your experience. The individual providing the verification must complete the lower portion and return this form directly to this office.
TO BE COMPLETED BY APPLICANT
Name of Applicant:

First NameLast Name
Date of Birth:

MonthDayYear
Social Security No.:
TO BE COMPLETED BY INDIVIDUAL PROVIDING VERIFICATION
Name of Individual verifying applicant’s experience:

First NameLast Name
Licenses held if any (give state or territory and license #):
Position held in institution:
Source of knowledge regarding applicant's experience:
Site of experience:
Name of Institution
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Inclusive dates of applicant's experience: From Date ToDate
Responsibilities carried out by applicant:
I understand in completing this verification that I may be asked to provide further documentation; I agree to provide written records upon the request of the Department of Public health to substantiate this verification of applicant's experience.
Signed:
Title:
State:
Date:

MonthDayYear
Daytime Telephone number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Please complete and return directly to:
Department of Public Health
Veterinary Licensure
410 Capitol Avenue MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1931
Should be Empty:

Public Health: Verification Of Licensed Work Experience As A Veterinarian

TO BE COMPLETED BY APPLICANT

TO BE COMPLETED BY INDIVIDUAL PROVIDING VERIFICATION