American College of Veterinary Radiology Specialty of Radiation Oncology - Certification Examination Application 2018

American College of Veterinary Radiology Radiation Oncology Exam Application 2022
Read and follow these instructions. Incomplete applications will NOT be accepted. Completed applications will NOT be accepted after January 31, 2022, and candidates will be required to apply for the 2023 Radiation Oncology Certification Examination.

Information about the ACVR Examinations are found at www.acvr.org/dashboard/resources/category/examination-resources/.

Questions can be directed to: acvr@pamedsoc.org

Application Directions:

Fill in the information requested on this form.

The application fee for the Certifying Examination is $1000.00 for the entire exam. The application fee is $500.00, if only retaking one section.

The ACVR (RO) Residency Standards Committee will review the completed application form. Additional information, needed for clarification, may be requested by the Residency Standards Committee.

You will be notified of your application status and exam details by RO Exam Committee.

Upon written request, received on or before August 1, in the year in which the exam is given, the application fee for the Certifying Examination is refundable (except for a $100.00 processing fee). The entire fee is forfeited after August 1.

Examination objectives are available on the ACVR website, https://acvr.org/dashboard/resources/acvr-ro-examination-homepage/.

This form includes:
1. Application for Certifying Examination
2. Statement of Completion of Training Program
3. Payment
Name*

First NameMiddle NameLast Name
Please send a current passport type photograph (2-1/4" x 3-1/4") with the application. This photograph will be used by the examiners and placed in the ACVR directory.*
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone Number*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Permanent Email (active for a year):*
Home Phone Number*

Area CodePhone Number
It is your responsiblity to notify the ACVR Executive Director and the Speciality of Radiation Oncology Examination Committee Chairman of any change in Name, Address, or Phone number.

Examination:
First time applicant or Re-application?*

First time applicantRe-application
Complete Exam or Section of the Exam?*

Taking the complete examinationRepeating a section of the examination
If you are repeating only one section of the examination, please select that section.

General basic and clinical knowledgeRadiation biology and related topicsClinical aspects of radiation oncologyPhysics and dose calculation
Please list the year(s) in which you took the examination, and indicate the results (pass or failure) of each part of the examination for each year.

Education:

In chronological order, beginning with the most recent, list the name and locations of schools attended since graduating from high school, dates of attendence, and degrees acquired or anticipated.
School 1*

School Name

City and State

DegreeDate Attended To/From

Graduation Date
School 2

School Name

City and State

DegreeDate Attended To/From

Graduation Date
School 3

School Name

City and State

DegreeDate Attended To/From

Graduation Date
School 4

School Name

City and State

DegreeDate Attended To/From

Graduation Date

Residency Program:
Did you ever complete an Approved Training Program in radiation oncology?

YesNo
If yes, give institution, completion date, and name of ACVR residency training director:

InstitutionCompletion DateACVR Residency Training Director
Did you complete an Alternate Training Program in radiation oncology?

YesNo
If yes, give institution, completion date, and name of ACVR residency training director:

InstitutionCompletion DateACVR Residency Training Director
Professional Activities:

Licensure:

List one state or country in which you have had a license to practice veterinary medicine, the date received, and the corresponding license number. If licensed outside the U.S., give the address of the licensing body. Include a copy of one of these documents (license to practice veterinary medicine in one (1) state, ECFVG certificate or diploma from AVMA accredited College or School of Veterinary Medicine) with this application.
Upload copy of license*

Upload a File

Cancelof
State (or Country)*
Expiration Date (MM/DD/YYYY)*
Address of Foreign Licensing Agency (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Moral/Ethical:
Has your license to practice veterinary medicine ever been revoked or temporarily suspended in any state or country?*

YesNo
If yes, give date(s), Location(s), and explain below.
Confidentiality Agreement:
By checking this box, I certify that I will keep details of the specific items included in the ACVR Specialty of Radiation Oncology Certification Examination confidential.*

I agree.
Documents to Upload:
Download the Statement of Completion Training Program. Fill it out and complete the form and upload it to your application completed.
Upload Statement of Completion of Training Program*

Upload a File

Cancelof

Payment

You MUST go to the ACVR Examination Fee Payment page to make your payment. Fee for the entire exam is $1000.00. $500.00 for the single section. Log into your ACVR User Profile and navigate to the link below.

https://acvr.org/product-category/examinations/
Provide your 6-digit "Order Number" from your exam payment receipt.*
Order Number is 5 digits.
By checking this box I acknowledge that I have submitted payment for the ACVR Examination fee.*

Payment submitted
Agreement:
I certify that the information submitted in this application is true and correct to the best of my knowledge.*

I agree.
By typing your name below you acknowledge and agree to the honor code. This serves as your electronic signature.*
Your Signature
Date: *

Appeal Process
ARTICLE VIII - Procedure for Appeal of Adverse Decisions by the American College of Veterinary Radiology

Section 1

Adverse decisions by the ACVR may include, but are not limited to:

a. Denial of certification of an individual.

b. Denial of examination application acceptance.

c. Denial of approval of a residency program.

d. Denial of privilege to vote or hold office.

Section 2

In the event of an adverse decision by ACVR, ACVR shall advise the affected party of the procedure for appealing the adverse decision.  The affected party is responsible for all his or her expenses incurred during the appeal process.  An affected party desiring to appeal the ACVR's adverse decision must adhere to the following procedure:

a. Grounds for Reconsideration or Review:

1. The affected party may petition for reconsideration or review of the ACVR's decision on the grounds that the ACVR has ruled erroneously by:

a) disregarding the established ACVR criteria for certification

b) failing to follow its stated procedures or

c) failing to consider relevant evidence and documentation presented.

b. Petition for Reconsideration:

1. An affected party may, at his or her option, petition ACVR to reconsider its decision by filing with ACVR a written petition for reconsideration which shall include a statement of the grounds for reconsideration and documentation, if any, in support of the petition.

2. Such petition must be received in the ACVR office within 90 days of the date on which ACVR announces its adverse decision.

3. Upon receipt of such a petition, the ACVR President will appoint an ad hoc committee to review the petition. This committee will comprise at least 3, and no more than 5, ACVR Active Diplomates who are not at the time of the petition members of the Executive Council, Examination Committee, or Residency Standards and Evaluation Committee.

4. The ad hoc committee will meet within 60 days of its formation to review the petition for reconsideration of an adverse decision. The affected party may, at his or her option, elect to appear at this meeting

5. The ad hoc committee will reach a final decision and this decision will be delivered in writing by email to the ACVR President and the affected party not more than 30 days after it is made.
I have read and understand the appeal process outlined above.*

I agree.
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American College of Veterinary Radiology Radiation Oncology Exam Application 2022

Read and follow these instructions. Incomplete applications will NOT be accepted. Completed applications will NOT be accepted after January 31, 2022, and candidates will be required to apply for the 2023 Radiation Oncology Certification Examination.

Information about the ACVR Examinations are found at www.acvr.org/dashboard/resources/category/examination-resources/.

Questions can be directed to: acvr@pamedsoc.org

Examination:

Residency Program:

Licensure:

Moral/Ethical:

Confidentiality Agreement:

Documents to Upload:

Payment

Agreement: