Application for a Veterinary Corporation Permit

Application for a Veterinary Corporation Permit
Name of corporation making the application (the “Corporation”):*
Name of licensed member completing the application form on behalf of the Corporation:*

First NameLast Name
Registered office address of the Corporation:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registered Office phone number:*
Please enter a valid phone number.
Registered Office fax number:
Please enter a valid fax number.
Registered Office email address:*
example@example.com
Business address of the Corporation, if different than the Corporation's registered office address shown above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business phone number:
Please enter a valid phone number.
Business fax number:
Please enter a valid fax number.
Business email address:
example@example.com
On behalf of the Corporation, I apply to the Manitoba Veterinary Medical Association for a permit under s. 17.4(1) of The Veterinary Medical Act, so that the Corporation may practice veterinary medicine in Manitoba.

I declare that:
1. I am a member of the Manitoba Veterinary Medical Association (“MVMA”) holding a valid license to practice veterinary medicine in Manitoba.*

Yes
2. The Corporation is incorporated, formed by amalgamation, or continued under The Corporations Act of Manitoba, and I enclose with this application a copy of all Articles of Incorporation and amendments thereto, as filed at the Manitoba Companies Office.*

Yes
3. The Corporation is an existing corporation and is in good standing under The Corporations Act.*

Yes
4. Each voting share of the Corporation is legally and beneficially owned by one or more of the following:

(a) one or more members of the MVMA, each holding a valid license to practice veterinary medicine in Manitoba; or,

(b) one or more veterinary corporations.
Add additional shareholders here:
Full name of shareholder, address, number and class of shares
5. Each other share in the capital stock of the Corporation is legally and beneficially owned by:

(a) a person who is a voting shareholder of the Corporation;

(b) the spouse, common-law partner, or child of a voting shareholder of the Corporation, or

(c) a corporation, each share of the capital stock of which is legally and beneficially owned by a person who also is a voting shareholder of the Corporation or the spouse, common-law partner, or child of a voting shareholder of the Corporation.
Add additional shareholders here:
Full name of shareholder, address, number and class of shares, relationship to voting shareholder
6. Each director of the Corporation is a licensed member of the Manitoba Veterinary Medical Association, entitled to practice veterinary medicine in the Province of Manitoba:
Add additional directors here:
Name of director, address
7. The President of the Corporation is a licensed member of the Manitoba Veterinary Medical Association, who is entitled to practice veterinary medicine in the Province of Manitoba
Name of the President
8. The only individuals who intend to practice veterinary medicine on behalf of the Corporation are:

(a) the following licensed members (that is, veterinarians) of the Manitoba Veterinary Medical Association, each of whom is entitled to practice veterinary medicine in the Province of Manitoba
Name of veterinarian

First NameLast Name
Name of veterinarian

First NameLast Name
Add additional veterinarians here:
Full name(s)
(b) the following members of the Manitoba Veterinary Medical Association, each of whom is registered as a veterinary technologist and entitled to practice veterinary medicine in the Province of Manitoba to the extent permitted and subject to the conditions and requirements imposed by the MVMA
Name of veterinary technologist

First NameLast Name
Name of veterinary technologist

First NameLast Name
Add additional veterinary technologists here:
Full name(s)
(c) the following members of the Manitoba Veterinary Medical Association, who are not already listed above at (a) or (b).
Name of MVMA member

First NameLast Name
Name of MVMA member

First NameLast Name
Add additional MVMA members here:
Full name(s)
(d) the following individuals who are not members of the Manitoba Veterinary Medical Association
Name of non-MVMA member

First NameLast Name
Name of non-MVMA member

First NameLast Name
Add additional non-MVMA members here:
Full name(s)
9. The Corporation will not carry on any business or activity other than the practice of veterinary medicine and the provision of services directly associated with that practice.*

Yes
10. I undertake to inform the Registrar of the Manitoba Veterinary Medical Association of any changes in the particulars set out in this permit application form within 15 days of those changes.*

Yes
Please indicate the PIPS inspected practice(s) that the veterinary corporation provides veterinary service through. If this is a holding corporation, please identify the PIPS inspected practice of the corresponding veterinary corporation.*
Corporation Contact Information

Please note that all correspondence related to the corporation will be sent to the email address provided below.
Contact Email Address*
example@example.com
Required Attachments
Please attach a copy of all Articles of Incorporation and amendments relating to the Corporation*

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Please attach a Certificate of Status or File Summary, as issued by the Manitoba Companies Office*

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Optional Attachment
If the applicant's legal representative is completing this form, you must attach documentation in which the applicant attests that 1) the information contained in this application is correct and 2) the applicant consents to the legal representative completing the Veterinary Corporation Permit Application on his or her behalf.

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Certification of the Corporation

The above-named Corporation certifies that, while it holds a valid permit issued pursuant to s. 17.4(1) of The Veterinary Medical Act, the Corporation will comply with every applicable provision of The Veterinary Medical Act, and the by-laws of the Manitoba Veterinary Medical Association, including without limiting the generality of the foregoing General By-Law No. 1.
Name of Corporation*
Date*

MonthDayYear
Date
Signature of Applicant or the Applicant's legal representative*

Clear
Printed Name of Applicant or the Applicant's legal representative*

First NameLast Name
Payment

The Veterinary Corporation Permit Application Fee is $153.30 ($146.00 plus GST). Please note that the Veterinary Corporation Permit Application Fee is due no later than 30 days after the submission of this application.
Payment*

I will pay by credit card below (Please ensure to check the box on the left hand side of the fee you are paying)I will pay by cheque. Please send cheques to the MVMA office.

My Products

Veterinary Corporation Permit Application Fee

$148.00CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

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

Should be Empty:

Application for a Veterinary Corporation Permit

Corporation Contact Information

Required Attachments

Optional Attachment

Certification of the Corporation

Payment