Serving Veterinary Regulatory Boards in the Interest of Public Protection

AAVSB Service Application

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* Indicates required field.

Personal Information *
First Name *
Middle Name
Last Name *
Suffix (Jr, III, etc)
Other Names Used?
(maiden name, nickname, etc)
Last 4 digits of Social Security or
SI(Canada) #
eg., 1234

Date Of Birth
Place Of Birth (city/state or province) *
Contact Information
Home Phone
eg., 999-999-9999
Work Phone    
Other Phone    
Email Address *
Re-enter Email Address *
NOTE: All our communication will come to you via EMAIL!
Address (U.S. or Canadian, if possible)
Address *
Address 2
City *
State or Province *
ZIP/Postal Code *
Alternate Address
Address 2
State or Province
ZIP/Postal Code
Special notes about this application
* AAVSB Requests your personal information including Social Security number or Canadian identification number and e-mail address for identification only. This information is not included on AAVSB reports and is not shared with other entities. Without sufficient identifiying information, AAVSB may be unable to comply with your request(s) for services.

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