2022 Veterinarian - Change of Membership Declaration Form

2022 Veterinarian Change of Membership Declaration Form
Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
I am making this declaration in regard to my intention to let my current licence, which is set to expire December 31, 2022, expire and change to the following category:*

Associate Member (Non-Practicing) - January 1 - June 30, 2023 (MVMA - $15 plus gst/CVMA - $166 plus GST)Retired Member (Non-Practicing) - January 1 - June 30, 2023 (MVMA - $15 plus gst)Let Membership Lapse (Free)
Declarations:

Please complete the following declarations:
1. I hereby confirm that I am currently registered with the MVMA, and that my registration is not suspended or cancelled.*

NoYes
2. I hereby confirm that I am not employed by nor hold any type of contractual or other agreement to provide veterinary medical service in the province of Manitoba, and will not undertake same prior to reinstating my eligibility to practice.*

NoYes
3. I hereby confirm that I will not engage in veterinary practice so long as I do not hold a licence with the MVMA.*

NoYes
4. I understand that any certification granted to me by the MVMA authorizing me to engage in veterinary practice will be revoked effective the date of this declaration.*

NoYes
5. I understand that, in the future, prior to returning to professional practice, I must apply to the MVMA, to obtain a license and agree to pay any applicable fees.*

NoYes
6. I understand that should I not renew my licence for two consecutive years, that my registration with the MVMA may be cancelled.*

NoYes
7. I hereby certify that the statements made by me in this declaration and all accompanying submissions are complete and accurate to the best of my knowledge and belief. I understand that a false or misleading statement may disqualify me from eligibility to practice in the future.*

NoYes
Veterinary Workforce Questions

To help the MVMA better understand the veterinary workforce, please complete the questions below. The MVMA will use this information to 1) help address issues veterinarians face 2) better understand the rates at which members take temporary leaves from the profession, and 3) better understand why members may make career changes or leave the profession.
To help the MVMA better understand why you are no longer practising, please provide a description below.
Why are you no longer practising:

RetirementLeaving the ProvinceCareer ChangeFamily LeaveOther
Do you intend to practice veterinary medicine in Manitoba at a future time?

yesno
Payment Information
Please select how payment will be made if applicable:

Credit Card belowMail cheque to the MVMA OfficeN/A (select if choosing lapse as no fee is required)

Please complete this section if paying by credit card.

Associate Member Fee (Non-Practicing)

January 1 - June 30, 2023 (MVMA - $15 plus gst/CVMA - $166 plus GST)

$190.05CAD

Retired Member Fee (Non-Practicing)

January 1 - June 30, 2023 (MVMA - $15 plus gst)

$15.75CAD

Lapse Membership

$ FreeCAD

Total

$0.00CAD

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

Date:*

MonthDayYear
Date
Signature*
Should be Empty:

2022 Veterinarian Change of Membership Declaration Form

Declarations:

Veterinary Workforce Questions

Payment Information