GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES  
DEPARTMENT OF HEALTH 
OFFICE OF PROFESSIONAL LICENSURE & HEALTH PLANNING  
 
TEMPORARY VETERINARY PERMIT REQUEST 
  
 
RELIEF VETERINARIAN - PLEASE TYPE (HANDWRITTEN APPLICATIONS ARE NOT ACCEPTED) 
DATE: MM/DD/YYYY
SUFFIX 
LAST 
MIDDLE 
FIRST 
   DOB: MM/DD/YYYY
LAST 4 DIGITS OF SS#
                            EMAIL ADDRESS
CELL PHONE #
MAILING ADDRESS
CITY 
STATE 
ZIP CODE 
REQUESTING VI DVM:
LICENSE #:
DATE(S) REQUESTED:
   PURPOSE FOR REQUEST: 
                                                         EDUCATION/TRAINING 
VETERINARY SCHOOL
GRADUATE
❑ YES                ❑ NO 
 GRADUATION YEAR
DEGREE
STATE/PROFESSIONAL CERTIFICATIONS 
STATE LICENSED
LICENSE #
LICENSE DATES
STATE LICENSED
LICENSE #
LICENSE DATES
LIABILITY CARRIER
POLICY #
START /END DATE
OFFICE USE ONLY
                           BACKGROUND INFORMATION 
    HAVE YOU WORKED IN THE VI PREVIOUSLY? IF YES, WHEN AND FOR WHOM? 
DO YOU HAVE ANY CURRENT OR PENDING DISCIPLINARY ISSUES ON YOUR RECORD?    ❑ YES    ❑ NO                
IF YES, PLEASE EXPLAIN: 
 
FROM: 
TO: 
HAVE YOU EVER UNDERGONE DISCIPLINARY HEARING?    ❑YES    ❑NO 
IF YES, PLEASE 
EXPLAIN:                                                                                                                                                                                                  
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR?    ❑YES    ❑NO                                            
IF YES, PLEASE EXPLAIN: 
 
I hereby affirm under the penalties of perjury that the statements made in this application are true, complete, and 
correct. I further wave, for process of this application, any confidentiality provisions concerning the information 
required to be provided to this application. 
__________________________________   ___________     ____________________________  __________ 
       Applicant’s Signature                                   Date                                    Witness Signature                           Date 
_________________________________________   _____________ 
                 Requesting VI DVM Signature                         Date 
 
 
 
 
 
 
 
 PLEASE BE SURE TO ATTACH: 
1. LEGIBLE COPY OF GOVERNMENT ISSUED IDENTIFICATION. 
2. COPY OF STATE LICENSE & VERIFICATION. 
3. COPY OF INSURANCE. 
4. COPY OF DIPLOMA. 
EMAIL TO: PLHPDOCUMENTS@DOH.VI.GOV 
 
 
 
 
Professional Licensure & Health Planning, VI Department of Health – P.O. Box 222995 Christiansted, VI 00822-2995  
Telephone: 340-718-1311 STX OR 340-774-7477 Ext. 5694 STT