Short Term Application

Prince Edward Island Veterinary Medical Association Application for Short-Term Membership & Licence

Short-Term Membership & Licence

I hereby make application for membership and licensure as:*
- Short-Term
Professional activity if application accepted: (check appropriate)
- 1 Small Animal
- 2 Large Animal
- 3 Equine
- 4-1 Mixed Practice (Primarily Large Animals)
- 4-2 Mixed Practice (Primarily Small Animals)
- 5 Government (any level)
- 6 Teaching
- 7 Research
- 8 Industry
- 9 Other (includes retired)
Full Name*
Prefix First Last
Date of Birth*
MM slash DD slash YYYY
Place of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email

The PEIVMA corresponds with its members by email. Provide your current email address. In doing so, you agree to accept correspondence from PEIVMA via email.
I DO SOLEMNLY DECLARE THAT:
My citizenship is:*
I graduated with a degree in Veterinary Medicine from:
- University or College*
- Year*
- Degree*
I have obtained the following other degrees:
- University or College
- Year
- Degree
- University or College
- Year
- Degree
4. If accepted and while so registered, I will act in a professional and becoming manner, in accordance with the Prince Edward Island Veterinary Medical Act and Bylaws, together with the Code of Ethics and Standards of Practice of the PEI Veterinary Medical Association.*
- Yes
- No
5. I have never been denied a license to practice veterinary medicine nor has my right to practice been suspended or revoked by any veterinary licensing body.*
- Yes
- No
6. I have no unresolved complaints registered against me and I am not currently under investigation by a veterinary licensing body.*
- Yes
- No
I have no disciplinary findings against me.*
- Yes
- No
8. I have never been convicted of any offence under the Criminal Code of Canada or the controlled Drugs & Substances Act (Canada), for which a pardon has not been granted, nor have I been convicted of any offence that is inconsistent with the proper professional behavior expected of a veterinarian.*
- Yes
- No
IF YOU ANSWERED “NO” TO ANY OF THE ABOVE QUESTIONS, NOTE THE NUMBER AND EXPLAIN HERE:
The facility in which I intend to practice will be an accredited facility.
Place of employment
Date of employment
Name of PEI veterinarian with whom you will be affiliated
I am licensed and eligible to practice veterinary medicine in the following jurisdiction and which is the jurisdiction which I consider as my principal licensing body. A Letter of Standing (Licence Verification) from this jurisdiction must be forwarded directly to the PEIVMA).*
Date First Issued*
MM slash DD slash YYYY
I am familiar with the Prince Edward Island Veterinary Medical Association (PEIVMA) Act and Bylaws and do solemnly declare my willingness to uphold the honour and dignity of the profession, that I will undertake to practice veterinary medicine in a professional and becoming manner and in accordance with the Act and Bylaws of the PEIVMA including any and all restrictions imposed by said Act and Bylaws, and that my name has not been removed from the register of any veterinary association by reason of an indictable offence. The information in this application is correct to the best of my knowledge, information and belief, and I understand and agree that, in the event that any information provided above is incorrect, the PEIVMA may suspend or cancel any registration or license granted by it. I also hereby authorize the Prince Edward Island Veterinary Medical Association (PEIVMA) to make those inquiries that it deems relevant to my application for membership and licensure in the PEIVMA from those educational institutions that I have attended and those professional associations of which I am or have been a member. I also hereby authorize those educational institutions and professional associations to provide to the PEIVMA all such information requested by it. The Prince Edward Island Veterinary Medical Association (PEIVMA) communicates with its members primarily through electronic means (e.g. email, electronic newsletters, etc.) I agree to accept electronic communications from the PEIVMA (express consent) and I will contact the PEIVMA office to unsubscribe should my wishes change in this regard.
Name*
Prefix First Last
Signature of Applicant*
Date*
MM slash DD slash YYYY
As Sponsoring Veterinarian, I, declare that I understand and accept the responsibilities as outlined in the Association Bylaws and agree to accept liability for the applicant, both in relation to the Association and the clients with whom the applicant comes into contact, and that I will be responsible for continuing after the applicant leaves Prince Edward Island any veterinary care started in Prince Edward Island by the applicant.
Name of Sponsoring Veterinarian*
Prefix First Last
Signature
Date*
MM slash DD slash YYYY
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An additional rush fee of $150.00+HST ($21.00) will be applied to applications requiring approval less than 3 weeks prior to start date.

A minimum of five business days must be given for processing.

Failure to provide all required documentation and fees will delay approval of application.

Forward complete application package with associated fees to Registrar, PEIVMA, Box 21097, 465 University Avenue, Charlottetown, PE, C1A 9H6

Please provide written notice to the registrar of resignation from the PEIVMA .

Short-Term Membership & Licence

I DO SOLEMNLY DECLARE THAT:

I graduated with a degree in Veterinary Medicine from:

I have obtained the following other degrees:

The facility in which I intend to practice will be an accredited facility.