CVPP APPLICATION

CVPP Application

DVM/VMD

Technician/Nurse

DVM/VMD

Technician/Nurse

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USD

Campaign

General Information

Applicant Registration Number *

First Name *

Last Name *

Prefix

Suffix

I am a *

DVM

VMD

CVT

LVT

RVT

Nurse

Other

Business Name *

Street Address *

Please submit business/work address

Address Line 2

City

State/Province

Zip/Postal Code

Country *

Business Phone *

Home Phone

Mobile Phone

Email *

Headshot *

Professional Experience

Highest Degree *

Institution *

Year Awarded *

Copy/copies of current professional license(s)/documentation to prove license to practice *

Copy of resume or curriculum vitae *

Major area of interest or specialty *

Are you Board certified? *

Yes

No

Copies of any other certificates

Professional memberships *

Briefly outline your experience in pain management. Include information about training, work experience, writing, research and teaching. *

Have you ever had a professional license suspended, revoked, or voluntarily relinquished? *

Yes

No

Have you ever had a professional certification suspended, revoked, or voluntarily relinquished? *

Yes

No

Have you ever been convicted of, or are you now under any charges for, any ethical violation? *

Yes

No

Application Requirements

Parts of this section will require you to upload forms, certificates and other types of documentation

Letter of Good Standing Contact Information: Please submit contact information for your reference letter in case additional follow up is necessary. I have read this statement and agree *

Yes

Letter of Good Standing Contact: Name *

Letter of Good Standing Contact Credentials *

Letter of Good Standing Contact Email *

Letter of Good Standing Contact Phone Number *

Continuing Education Record - Conference / CE Provider *

Continuing Education Record - Date *

Continuing Education Record - # of hours *

CE Certificates / Internship-Observation Record Form indicating proof of completion *

Skills Verification of Pain Management Skills Form *

Digital Images of Pain Management Elements: Allopathic *

Digital Images of Pain Management Elements: Rehabilitation *

Digital Images of Pain Management Elements: Acupuncture *

Case Reports *

The case reports should be saved in a PDF format. Please use your application registration number (ARN) to name them as follows: ARN xx-xxxxxx-xx case report 1 and ARN xx-xxxxxx-xx case report 2

Do you require ADA Exam Accommodations? *

Yes

No

Please describe the type of accommodations requested/needed:

Applicants requesting ADA examination accommodations must submit medical and/or psychological documentation from a qualified professional below:

Acknowledgment: I do hereby make a voluntary application for certification from IVAPM. I certify that the information given by way of this application is true, honest, and completely represents me. I understand and agree that if I am awarded Certification, I will conform to all applicable local and governmental regulations and will conduct my professional behavior consistent with the highest standards of professional conduct, as established in the Code of Ethics of the IVAPM, as well as those codes of ethical conduct relating to my specialty. I agree to abide by the regulations of the IVAPM and I recognize that failure to do so may result in suspension or revocation of my standing within this organization. I understand that any credential by the IVAPM does not in and of itself imply or grant license to practice in any country or state. Furthermore, I understand and agree that the IVAPM and its affiliates assume no responsibility for my action or activities. I practice at my own risk and hereby release the IVAPM from any and all liability from any practice decision I make in the practice of veterinary pain management.

Yes

Data Privacy & Consent

Yes, I would like to receive communications from International Veterinary Academy of Pain Management by email.

Yes, I would like to receive communications from International Veterinary Academy of Pain Management by phone.

Yes, I would like to receive communications from International Veterinary Academy of Pain Management by mail.

Yes, I would like to receive text messages from International Veterinary Academy of Pain Management.

Payment Details

Card

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Cardholder First Name *

Cardholder Last Name *

Cardholder Email

Card *

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Address Line 1

Address Line 2

City

State/Province

Zip *

Country