Dca Form 25A 1 PDF Details

The DCA 25A 1 form serves a pivotal role within the California Veterinary Medical Board under the governance of the Business, Consumer Services, and Housing Agency, setting the fundamental steps for applying for a veterinary license in the state. This comprehensive document, created to streamline the application process, encompasses various crucial sections, from detailing the required fees, such as the application evaluation fee, state board examination fee, and, if applicable, the California Veterinary Law Examination fee, to providing personal, educational, and professional information. Applicants must disclose their full details including their physical description and attach a passport-size photo, outline their educational background including colleges or universities attended along with degrees received, and list any states or provinces where they currently hold a veterinary license. Moreover, the form mandates disclosure of previous applications to practice in California, any disciplinary actions against the applicant's professional practice, and convictions for misdemeanors or felonies, ensuring thorough scrutiny for the protection of public and animal health. It also offers an expedited application process for the spouses or domestic partners of active-duty military personnel, highlighting the board's support for military families. By certifying the application, applicants understand their obligation to report any convictions or disciplinary actions during the application process and acknowledge that failure to provide complete and truthful information can lead to the denial or revocation of licensure, emphasizing the seriousness and importance of the information provided in the pursuit of veterinary licensure in California.

QuestionAnswer
Form NameDca Form 25A 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfalse, 25A-1, online application for veterinary, BIRTHDATE

Form Preview Example

BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.

Veterinary Medical Board

1747 N. Market Boulevard, Suite 230, Sacramento, CA 95834 Telephone: 916-515-5220 Fax: 916-928-6849 | www.vmb.ca.gov

VETERINARY APPLICATION

1.APPLICATION TYPE/FEES - check fees you are paying

 

$125.00 - Application Evaluation Fee

 

 

 

 

 

 

 

 

 

Office Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Application Fee is Required for all Applications

 

 

 

 

 

Receipt

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$200.00 - State Board Examination Fee

 

 

 

 

Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

_______________________________

 

 

$100.00 - California Veterinary Law Examination Fee, if

 

 

Cashiered:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

applicable

 

 

 

 

 

 

 

 

 

 

ATS ID:

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please make check or money order payable to the “VMB”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mail application, supporting documents, and fee to:

 

 

 

 

 

 

 

 

 

Paid:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Veterinary Medical Board

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________

 

 

1747 N. Market Blvd., Suite 230

 

 

 

 

 

Refund:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sacramento, CA 95834

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. APPLICANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST

FIRST

 

 

 

 

MIDDLE

 

 

 

 

BIRTHDATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT MAILING ADDRESS

 

 

 

CITY

 

 

STATE

 

 

ZIP

 

 

 

 

COUNTRY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERMANENT MAILING ADDRESS

 

 

 

CITY

 

 

STATE

 

 

ZIP

 

 

 

 

COUNTRY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. SOCIAL SECURITY NUMBER*:

 

 

 

 

 

 

 

TELEPHONE NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMAIL ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Disclosure of a social security number is mandatory and must be provided prior to licensure This number must be a United States social security number. Social security

 

numbers from other countries will not be accepted. Section 30 of the Business and Profession Code and Public Law 94-455 [42 USC 405(c)(2)(C)] authorize collection of the

 

Social Security number. Your Social Security number will be used exclusively for tax enforcement purposes and for purposes of compliance with any judgment or support order

 

in accordance with Section 17520 of the Family Code.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. PHYSICAL DESCRIPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAIR COLOR

 

HEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EYE COLOR

 

WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACH PASSPORT

I HEREBY DECLARE THAT THE ATTACHED PHOTO

 

 

 

 

 

 

 

 

 

 

 

SIZE PHOTO HERE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WAS TAKEN ON OR ABOUT (MONTH/DAY/YEAR):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CANDIDATE SIGNATURE ___________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. EDUCATION INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COLLEGE OR UNIVERSITY

 

 

 

FROM

 

TO

 

 

COURSE

 

 

GRADUATION DATE

DEGREE RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. STATES/PROVINCES IN WHICH YOU ARE LICENSED AS A VETERINARIAN

STATE/PROVINCE

REGISTRATION #

 

 

DATE ISSUED

ISSUED BY EXAM OR CREDENTIALS

PERIOD OF PRACTICE

6. PREVIOUS APPLICATION(S) FOR CALIFORNIA

HAVE YOU EVER APPLIED TO TAKE THE VETERINARY EXAMINATION IN CALIFORNIA?

YES

NO

7. DISCLOSURE OF DISCIPLINARY ACTION

HAVE YOU EVER HAD DISCIPLINARY PROCEEDINGS AGAINST ANY LICENSE TO PRACTICE VETERINARY MEDICINE INCLUDING REVOCATION, SUSPENSION, PROBATION, VOLUNTARY SURRENDER, OR ANY OTHER PROCEEDING?

If Yes, please provide detailed written explanation, include the date and state where the discipline occurred.

YES

NO

8. CONVICTION OF MISDEMEANOR OR FELONY

HAVE YOU EVER BEEN CONVICTED OF ANY OFFENSE OTHER THAN MINOR TRAFFIC VIOLATIONS OR PLED NO CONTEST TO A VIOLATION OF ANY LAW OF ANY STATE, THE UNITED STATES, OR A FOREIGN COUNTRY?

If Yes, please provide detailed written explanation.*

YES

NO

*You must include all misdemeanor and felony convictions, regardless of the age of the conviction, including those which have been set aside and/or dismissed under Penal Code Section 1000, 1203.4 or 1210.1. Traffic violations involving driving under the influence, injury to persons or providing false information must be reported. The definition of conviction includes convictions following a plea of nolo contendere (no contest) as well as pleas or verdicts of guilty.

9. EXPEDITED APPLICATION FOR SPOUSES OR DOMESTIC PARTNERS OR ACTIVE DUTY MILITARY PERSONNEL

ARE YOU A SPOUSE OR DOMESTIC PARTNER OF ACTIVE DUTY MILITARY PERSONNEL?

If Yes, you may qualify for expedited application processing.*

YES

NO

*An applicant for expedited application processing must meet the following requirements: 1) provide evidence that the applicant is married to, or in a domestic partnership or other legal union with, an active duty member of the Armed Forces of the United States who is assigned to a duty station in California under official active duty orders and, 2) hold a current license in another state, district, or territory of the United States in veterinary medicine.

10. CERTIFICATION SIGNATURE AND DATE

I understand that I am required to report immediately to the California Veterinary Medical Board if I am convicted of any offense that occurs between the date of this application and the date that a California veterinary license is issued. I am also required to report to the California Veterinary Medical Board any disciplinary action and/or voluntary surrender against any license as a veterinarian or any veterinary related license that occurs between the date of this application and the date that a California veterinary license is issued. I understand that failure to do so may result in denial of this application or subsequent disciplinary action against my license.

I certify, under penalty of perjury under the laws of the State of California, that all information provided in connection with this application for licensure examination is true, correct, and complete. Providing false information or omitting required information is grounds for denial of licensure or revocation of licensure in California.

Signature of applicant_____________________________________________________________ Date__________________________

NOTE: All items in this application are mandatory; none are voluntary, unless indicated. Failure to provide any of the requested information will result in the application being deemed incomplete. The information provided will be used to determine qualification for examination and licensure, per Section 4841-4842 of the Business and Professions Code which authorizes the collection of this information. Information regarding the issuance or denial of a license by the Board may be transmitted to any other veterinary medical licensing authority. Candidates have the right to review their application subject to the provisions of the Information Practice Act. The Executive Officer is custodian of records.

INFORMATION COLLECTION, ACCESS, & DISCLOSURE: Information you provide on this application is maintained by the Executive Officer of the Veterinary Medical Board, 1747 N. Market Blvd., Suite 230, Sacramento, CA 95834. The information is requested pursuant to Business and Professions Code sections 4832-4844 and/or Title 16, California Code of Regulations, Division 20, Article 6.

FORM 25A-1 (Rev. 09/2010)

How to Edit Dca Form 25A 1 Online for Free

There is nothing complicated concerning filling in the application for veterinary if you use our PDF editor. Following these simple actions, you will have the ready file in the least time frame you can.

Step 1: The very first step requires you to press the orange "Get Form Now" button.

Step 2: Now you are going to be on your file edit page. You'll be able to add, adjust, highlight, check, cross, include or remove fields or phrases.

The next segments will create the PDF document that you'll be creating:

part 1 to filling in USC

Provide the required data in the segment PHYSICAL DESCRIPTION HAIR COLOR, EYE COLOR, HEIGHT, WEIGHT, I HEREBY DECLARE THAT THE ATTACHED, ATTACH PASSPORT SIZE PHOTO HERE, CANDIDATE SIGNATURE, EDUCATION INFORMATION COLLEGE OR, FROM, COURSE, and GRADUATION DATE DEGREE RECEIVED.

Filling in USC step 2

You may be expected to enter the details to let the software prepare the segment STATEPROVINCE, REGISTRATION, DATE ISSUED, ISSUED BY EXAM OR CREDENTIALS, PERIOD OF PRACTICE, PREVIOUS APPLICATIONS FOR, HAVE YOU EVER APPLIED TO TAKE THE, YES, DISCLOSURE OF DISCIPLINARY ACTION, YES, If Yes please provide detailed, CONVICTION OF MISDEMEANOR OR, YES, If Yes please provide detailed, and You must include all misdemeanor.

step 3 to entering details in USC

The I certify under penalty of perjury, Signature of applicant Date, NOTE All items in this application, INFORMATION COLLECTION ACCESS, and FORM A Rev field could be used to point out the rights and obligations of either side.

step 4 to completing USC

Step 3: Hit the button "Done". The PDF file may be exported. You will be able obtain it to your laptop or send it by email.

Step 4: Create duplicates of your form - it can help you stay away from future worries. And don't worry - we are not meant to disclose or read your details.

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