PIPS Self-Inspection Reporting Form- Temporary Certificate (6 Months)

Part B- Contact Information
The information contained in this section will be used for the following:

- Communication with the PIPS Inspected Practice for upcoming inspections
- Communication with the PIPS Inspected Practice about correcting deficiencies
- Communication with the PIPS Inspected Practice to collect information requested in complaints

This information will not be published to the public at large; however, it will be shared within the MVMA office and to MVMA contractors in the enforcement of The Veterinary Medical Act, the MVMA’s By-Laws and Code of Ethics.
B1. Contact Person Name*

First NameLast Name
B2. Contact Email Address (PIPS information will be sent to this address)*
example@example.com
B3. Contact Telephone Number*
Please enter a valid phone number.

PART C2: Self-Inspection Report
To complete a Self-Inspection, the Practice owner (or representative for all of the owners) must inspect the Practice for each applicable by-law under The Practice Inspections and Practice Standards By-laws (available on the MVMA website at https://www.mvma.ca/legislation-and-by-laws/). For each by-law where the practice is not in compliance with the specific by-law, the practice owner must report same in the table below.
C2.1) Deficiencies Statement*

During the inspection NO deficiencies were identifiedDuring the inspection deficiencies were identified. I have completed the Deficiencies Report below.
DEFICIENCIES ITEM 1
DEFICIENCIES ITEM 2
DEFICIENCIES ITEM 3
DEFICIENCIES ITEM 4
DEFICIENCIES ITEM 5
DEFICIENCIES ITEM 6
Please include any additional deficiencies here:
By-law section, description of issue, plan to correct

PART C3: Practice Owner Undertaking
As Owner of, or as a representative for all of the Owners (including myself) of (name of clinic)*, I hereby undertake to correct any deficiencies noted at the time of this inspection within the time period specified by the Registrar; AND continue, after such corrections have been made, to maintain complete compliance with the Practice Inspections and Practice Standards By-laws throughout the interim period to the time of the next inspection of the clinic.
I hereby certify that the information on this form is true and correct to the best of my knowledge.
If the Practice Owner's Authorized Representative is completing this form, you must attach documentation in which the Practice Owner(s) attests that 1) the information contained in this form is correct and 2) the Practice Owner(s) consents to the legal representative completing the form on his or her behalf.

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Cancelof
Practice Owner or Authorized Representative Signature*

Clear
Printed Name of Signatory*

First NameLast Name
Date*

MonthDayYear
Date

Part D- Payment

The Self-Inspection Fee is $204.75 ($195.00, plus $9.75 GST). Please note that the Self-Inspection Fee is due no later than 30 days after the submission of this Self-Inspection.
Payment*

I will pay by credit card belowI will pay by cheque. Please send cheques to the MVMA office.

My Products (only select this option if paying by credit card)

PIPS Self-Inspection Fee$195.00 + $9.75 GST = $204.75

$204.75CAD

Total

$0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

PIPS Self-Inspection Reporting Form- Temporary Certificate (6 Months)

Part A- Practice Info

Part B- Contact Information

PART C: Self Inspection Information

PART C1

PART C2: Self-Inspection Report

PART C3: Practice Owner Undertaking

Part D- Payment