Veterinarian Application

Legal Name*

First NameMiddle NameLast Name

Preferred Name*

First NameMiddle NameLast Name

Maiden Name (if applicable)

Other name(s) (if applicable)

Date of Birth*

Date

Upload a clear copy of a valid government issued photo ID (passport, drivers licence, Manitoba ID card) here. Your application is not complete until this is received.*

I am applying under the following pathway*

Route 1- Labour Mobility (CFTA)Route 2- Certificate of QualificationRoute 3- NEB Exam RouteRoute 4- Limited Licence- Board CertificationRoute 5- Limited Licence- Residency ProgramRoute 6- Limited Licence- InternshipRoute 7- CVMA/AVMA Accredited Graduate without NAVLE

I am applying for the following membership type:*

General Veterinarian MemberPublic Veterinarian MemberNon-Practicing/Retired Member

I will provide the following to prove that I am eligible to work in Canada:*

Canadian PassportCanadian Birth CertificateCanadian Citizenship CardCanadian Permanent Resident CardCanadian Work PermitI am not currently eligible to work in Canada. I understand that I cannot work in Manitoba until I obtain authorization.

Upload a clear copy of the document selected above. This can be provided following application submission.

Residential Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.

Secondary Phone Number

Please enter a valid phone number.

Correspondence Email Address*

example@example.com

I am applying for registration under the following qualification:*

Graduation from a CVMA or AVMA accredited DVM program prior to 1986Certificate of Qualification

I am a graduate of an educational institution that is not accredited by the CVMA or AVMA and am in the process of obtaining a Certificate of Qualification from the CVMA National Examining Board. I have successfully completed the following exams:*

The Basic and Clinical Sciences Examinations (BCSE)The North American Veterinary Licensing Examination (NAVLE)I have registered for the Preliminary Surgical Assessment (PSA)The Preliminary Surgical Assessment (PSA)The Clinical Proficiency Examination (CPE)

Please indicate the statement that applies to your situation:

I have obtained Board Certification through the American Board of Veterinary Specialties (ABVS)I have not obtained Board Certification through the American Board of Veterinary Specialties (ABVS). I have the equivalent training and experience of a Board Certification through the American Board of Veterinary Specialties (ABVS).

I have obtained Board Certification through the following American Board of Veterinary Specialties (ABVS):

Please upload a document with evidence that you have the equivalent training and experience of a Board Certification through the American Board of Veterinary Specialties (ABVS).

I confirm that I am a graduate of a CVMA or AVMA accredited DVM program and that*

I am registered for the next sitting of the North American Veterinary Licensing Examination (NAVLE) and have not had more than two previous NAVLE attemptsI am enrolled in the National Examining Board program.

I confirm that I am obtaining this registration for the purpose of practising veterinary medicine through an internship.*

Yes

I confirm that a practising veterinarian member who is board certified by, or a Diplomate of a veterinary specialty organization that is recognized by the AVMA American Board of Veterinary Specialties (ABVS), or equivalent, has agreed to serve as the primary supervisor*

Yes

Name of Primary Supervisor*

My internship will be hosted by the supervising veterinarian from Date* to Date .

I consent to the MVMA obtaining information from the primary supervisor regarding my application*

Yes

I confirm that I am obtaining this registration for the purpose of practising veterinary medicine while I am enrolled in a residency program of a veterinary specialty organization that is recognized by the AVMA American Board of Veterinary Specialties (ABVS).*

Yes

Program Start Date*

Date

Anticipated Completion date (Month, Year)*

Name of Specialty*

I am applying as a Labour Mobility applicant under the Canadian Free Trade Agreement. I am currently licensed in the following Canadian jurisdiction(s):*

College or University of graduation*

Year of graduation*

Country of College/University*

Please upload a clear copy of your diploma. This can be provided following application submission.

I have practiced or am currently practising veterinary medicine in another regulated jurisdiction (worldwide).*

YesNo

Below, you must report each jurisdiction (worldwide) where you have practised or been licensed to practice veterinary medicine. For each juisdiction, report the Province/State, Country, and Time Period. If you worked in the same jurisdiction over multiple interupted time periods, please complete a new field for each time period.

Please note that a Letter of Standing must be sent from each jurisdiction directly to the MVMA at mvmainfo@mvma.ca.

Province/State* - Country* - Start Date* to
End Date

Province/State - Country - Start Date to
End Date

Province/State - Country - Start Date to End Date

Province/State - Country - Start Date to
End Date

I understand that, as a condition of licensure, the MVMA requires that a licensed member have professional liability insurance in an amount deemed reasonable by the scope of their practice. (NOTE: In some cases, professional liability insurance is carried for veterinarians by the clinic owner or government employer. It is the responsibility of each individual veterinarian to ensure that they hold adequate professional liability insurance). I further understand the Registrar can demand, at any time, a copy of such insurance be delivered to the MVMA office.*

Yes

Professional Liability Insurance Declaration*

I HEREBY CERTIFY that I am covered by a professional liability insurance policy that is current and adequate, and I shall maintain adequate professional liability insurance for so long as I practice veterinary medicine in Manitoba.My scope of practice does not require professional liability insurance (specifics provided below)I am not currently covered by a professional liability insurance policy that is current and adequate. I will obtain same prior to practising, and I shall maintain adequate professional liability insurance for so long as I practice veterinary medicine in Manitoba.

Policy Carrier*

Policy Number*

Policy Expiry Date*

Date

My scope of practice does not require professional liability insurance as: (provide details below)*

1) While attending a post-secondary institution, have allegations of misconduct, including academic misconduct, ever been made against you or have you ever been suspended,required to withdraw, expelled or penalized by a post-secondary institution for misconduct?*

YesNo