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APPLICATION TO RENEW LICENSE TO PRACTICE VETERINARY ...

By Judith Foster,2014-04-29 06:21
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APPLICATION TO RENEW LICENSE TO PRACTICE VETERINARY ...APPL

    APPLICATION TO ANNUALLY RENEW CERTIFICATION / LICENSURE

    LOUISIANA BOARD OF VETERINARY MEDICINE

    263 THIRD STREET, SUITE 104 BATON ROUGE, LOUISIANA 70801 (225) 342-2176 www.lsbvm.org

    Please PRINT and complete all information on form. If information is not applicable to you, enter “NA”. DO NOT LEAVE BLANKS. Mail completed form with payment of appropriate fee(s) and proof of continuing education if applicable to address above. Annual renewal period is July 1 through September 30 Renewals will not be accepted prior to July 1.

     Indicate type of certificate/license being renewed:

     Veterinarian (DVM) Veterinary Technician (RVT) Animal Euthanasia Technician (CAET) Equine Dentist (RED)

     License/Certificate Number: Name

     Name of Clinic/Facility

     Clinic/Facility Address Home Address

     City State Zip City State Zip

     Clinic Telephone Fax Home Telephone

     Clinic/Facility Physical Address if different from above Email address

     Indicate here if you prefer to receive all correspondence from the Board at the home address indicated instead of the professional address.

All certificate holders/licensees!

    REQUIRED INFORMATION: If an item does not apply to you, enter “NA” in space provided. DEA and State Narcotic numbers should be provided by Louisiana practicing veterinarians and animal euthanasia technicians, if applicable. List all other STATE: LICENSE NO.: States in which you are SOCIAL SECURITY NO.: currently licensed: DATE OF BIRTH:

    DEA REG. NO.:

    LA/DHH-CDS REG. NO.:

Veterinarians ONLY!

    PRACTICE CODES: Please use codes given on code list provided.

     PROFESSION TYPE: EMPLOYMENT DESCRIPTION: EMPLOYMENT FUNCTION:

    SPECIAL COMPETENCE STATUS: If you are currently certified in a particular field of veterinary medicine by an AVMA recognized

    specialty organization, you may register your special competency with the LBVM in accordance with Board promulgated rule 1063. Registration of this certification would allow you to legally indicate the specialty on or in various items such as letterhead, business cards, and advertisements.

     Specialty Organization

All certificate holders/licensees!

     No Yes TO THE BEST OF YOUR KNOWLEDGE, HAVE YOU HAD OR DO YOU CURRENTLY HAVE ANY DISCIPLINARY INVESTIGATIONS AND/OR ACTIONS PENDING AGAINST YOU IN ANY STATE OR TERRITORY? WITHIN THE PAST 12 MONTHS: No Yes HAS ANY LICENSE PRESENTLY OR PREVIOUSLY HELD BY YOU EVER BEEN SANCTIONED, REVOKED, SUSPENED, PLACED ON PROBATION AND/OR OTHERWISE BEEN THE SUBJECT OF DISCIPLINARY ACTION IN ANOTHER JURSIDICTION? No Yes HAVE YOU BEEN CONVICTED OF, PLED GUILTY TO, OR PLED NOLO CONTENDRE TO A FELONY OR MISDEMEANOR, OTHER THAN FOR MINOR TRAFFIC VIOLATIONS? No Yes HAVE YOU ENGAGED OR ARE YOU CURRENTLY ENGAGING IN THE ABUSE OF ALCOHOL AND/OR ILLEGAL USE OF DRUGS OR CONTROLLED DANGEROUS SUBSTANCES? No Yes ARE YOU CURRENTLY PARTICIPATING IN A SUPERVISED REHABILITATION PROGRAM OR PROFESSIONAL ASSISTANCE PROGRAM WITH REGARDS TO THE ABUSE OF ALCOHOL AND/OR ILLEGAL USE OF DRUGS OR CONTROLLED SUBSTANCES?

Animal Euthanasia Technicians ONLY!

     Yes No (1) Are you currently using sodium pentobarbital for euthanasia? Yes No (2) Are you currently using Tiletamine HCl and Zolazepam HCl and/or Ketamine HCl for capture/restraint? Yes No If “Yes”, have you completed a Board-approved chemical capture course? Yes No (3) Are you currently using any other controlled substances for capture, restraint, or euthanasia? If “Yes”, list agents (4) If “Yes” to any question above, under whose authority are you obtaining the controlled substances (name of CAET with DEA & CDS registration)? Self Other

    RENEWAL: Veterinarians ONLY! Indicate here if a change of status is being made at this time. SELECT A STATUS AND PAY THE FEE SHOWN. Annual renewal fees must be paid to renew certificates/licenses. Make Check Payable to LBVM (Louisiana Board of Veterinary Medicine).

    ; DVM - ACTIVE Annual fee is $225. Twenty (20) hours of CE are required.

    ; DVM - FACULTY (ONLY for use by individuals who currently hold an existing Louisiana Faculty license.) Annual fee is $100.

    Twenty (20) hours of CE are required.

    ; DVM - INACTIVE Annual fee is $100. Twenty (20) hours of CE are required. NOTE: An INACTIVE license is intended for persons

    who wish to retain a Louisiana license, but who will not practice in the state of Louisiana.

    ; DVM - INACTIVE-RETIRED Annual fee is $100. An Affidavit of Retirement is required to be on file with the board office. No CE

    hours are required. Reversal of Retired status requires full Board review and approval. ; DVM - INACTIVE-INCAPACITATED Annual fee is $100. An Affidavit of Incapacibility and a Physician’s Statement are required

    to be filed annually with renewal form. Twenty (20) hours of CE are required. Reversal of incapacitated

    status requires a physician’s statement and Board review and approval.

    ; RVT Annual fee is $30. Ten (10) hours of CE are required.

    ; CAET Annual fee is $50. Six (6) hours of CE are required.

    ; RED Annual fee is $125. Six (6) hours of CE are required.

CONTINUING EDUCATION: All licensee and certificate holders -

    Attach acceptable proof of attendance for the minimum number of hours of approved continuing education as indicated in above section. Enter the total number of hours attached in the space at right.

    Renewals submitted with less than the required number of hours will be returned as partial/ incomplete renewals.

    Veterinarians ONLY! If hours were taken after the June 30 CE deadline, a late CE fee of $25 must be

    included with this renewal submission.

    The LATE RENEWAL FEE is due on all renewals not postmarked by midnight SEPTEMBER 30. PLEASE NOTE: Partial submissions will not be accepted or processed. Renewals returned to you because they are incomplete are not processed. Please mail EARLY. Late fees will apply to returned forms not re-submitted to the board office postmarked by September 30.

    Late fees are as follows: DVMs - $125 RVTs - $20 CAETs - $25 REDs - $100.

ALL RENEWAL FORMS MUST BE SIGNED:

The renewal period is July 1 through September 30 each year. Renewals will not be accepted prior to July 1.

     Your Legal Signature Date Signed

    Verification of your renewal should be mailed to you within approximately three weeks.

    If you do not receive it in that time frame, please contact the board office.

FOR OFFICE USE:

    Fiscal Year: License Status: Fee Status: CE Status:

    Check No.: Amount: $ Pmt Description: By:

    Check No.: Amount: $ Pmt Description: By:

    Check No.: Amount: $ Pmt Description: By:

    Web11-RnwlFormStndrd Rev. 10/11/2011

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