Dca Form 25A 1 PDF Details

Dca Form 25A 1 isn't exactly the most exciting form to read, but it's important nonetheless. This form is used to apply for a Certificate of Release or Discharge from Active Duty, more commonly known as a DD-214. If you're retiring from the military, this is the form you'll need to fill out in order to get your discharge papers. Thankfully, the process is relatively straightforward and can usually be completed online.

Below, you can find a number of details about dca form 25a 1 PDF. It is really worth making the effort to learn this just before you start filling in your form.

QuestionAnswer
Form NameDca Form 25A 1
Form Length2 pages
Fillable?Yes
Fillable fields55
Avg. time to fill out11 min 34 sec
Other namesREVOCATION, vetanary application, 2005, false

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)

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Step 2: So you are going to be on your file edit page. It's possible to add, customize, highlight, check, cross, add or remove areas or words.

These particular parts are what you will need to fill in to receive the prepared PDF file.

California blanks to fill out

Indicate the details in EYE COLOR, WEIGHT, I HEREBY DECLARE THAT THE ATTACHED, ATTACH PASSPORT SIZE PHOTO HERE, CANDIDATE SIGNATURE, COLLEGE OR UNIVERSITY, FROM, COURSE, and GRADUATION DATE DEGREE RECEIVED.

California EYE COLOR, WEIGHT, I HEREBY DECLARE THAT THE ATTACHED, ATTACH PASSPORT SIZE PHOTO HERE, CANDIDATE SIGNATURE, COLLEGE OR UNIVERSITY, FROM, COURSE, and GRADUATION DATE DEGREE RECEIVED blanks to complete

The program will ask you for details to instantly fill out the area STATE/PROVINCE, REGISTRATION #, DATE ISSUED, ISSUED BY EXAM OR CREDENTIALS, PERIOD OF PRACTICE, HAVE YOU EVER APPLIED TO TAKE THE, YES, HAVE YOU EVER HAD DISCIPLINARY, and YES.

California STATE/PROVINCE, REGISTRATION #, DATE ISSUED, ISSUED BY EXAM OR CREDENTIALS, PERIOD OF PRACTICE, HAVE YOU EVER APPLIED TO TAKE THE, YES, HAVE YOU EVER HAD DISCIPLINARY, and YES blanks to insert

The I understand that I am required to, and NOTE: All items in this area may be used to point out the rights and obligations of each party.

California I understand that I am required to, and NOTE: All items in this fields to insert

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