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

I am applying for the following membership type:

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

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.Format: (000) 000-0000.

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Correspondence Email Address

example@example.com

I am applying for registration under the following 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:

Please indicate the statement that applies to your situation:

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

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

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

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).

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).

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.

Professional Liability Insurance Declaration

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?