CVPP Application

Applicant Registration Number*

Name*

Prefix First Last Suffix

I am a*

Business Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone*

Home Phone

Mobile Phone

Email Address*

Enter Email Confirm Email

Headshot*

Drop files here or

Accepted file types: jpg, gif, png, tif, pdf, psd, bmp, Max. file size: 64 MB.

Professional Experience

Academic Degree*

Highest Degree	Institution	Year Awarded

Copy/copies of current professional license(s)/documentation to prove license to practice*

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

Copy of resume or curriculum vitae*

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

Major area of interest or specialty*

Are you Board certified?*

Yes
No

Copies of Board certificates*

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

Copies of any other certificates

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

Professional memberships*

Briefly outline your experience in pain management. Include information about training, work experience, writing, research and teaching.*

Have you ever had a professional license suspended, revoked, or voluntarily relinquished?*

Yes
No

Please Explain*

Have you ever had a professional certification suspended, revoked, or voluntarily relinquished?*

Yes
No

Please Explain*

Have you ever been convicted of, or are you now under any charges for, any ethical violation?*

Yes
No

Please Explain*

Application Requirements

Parts of this section will require you to upload forms, certificates and other types of documentation.

Letter of Good Standing Contact Information: Please submit contact information for your reference letter in case additional follow up is necessary.*

I have read this statement and agree.

Letter of Good Standing Contact:*

Name	Credentials	Email	Phone Number

Continuing Education Record*

Conference / CE Provider	Date (dd/mm/yyyy)	# of Hours

CE Certificates / Internship-Observation Record Form indicating proof of completion*

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

Skills Verification of Pain Management Skills Form*

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

Digital Images of Pain Management Elements: Allopathic

Drop files here or

Accepted file types: jpg, gif, png, tif, pdf, psd, bmp, Max. file size: 64 MB.

Digital Images of Pain Management Elements: Rehabilitation

Drop files here or

Accepted file types: jpg, gif, png, tif, pdf, psd, bmp, Max. file size: 64 MB.

Digital Images of Pain Management Elements: Acupuncture

Drop files here or

Accepted file types: jpg, gif, png, tif, pdf, psd, bmp, Max. file size: 64 MB.

Case Reports*

Drop files here or

Accepted file types: doc, docx, pdf, Max. file size: 64 MB.

The case reports should be saved in a PDF format. Please use your application registration number (ARN) to name them as follows: ARN xx-xxxxxx-xx case report 1 and ARN xx-xxxxxx-xx case report 2.

Examination Information

The exam is offered once a year in September as an on-site examination in conjunction with IVAPM’s annual meeting. It is also offered online at various test sites. The exam fees (separate from application fees) are: $250.00 for DVM/VMD and $150.00 for Technician/Nurse. Applicants eligible to take the exam will receive a notification requesting exams fees. The examination fees are due 30 days prior to the examination.

Do you require ADA Exam Accommodations?*

Yes
No

Please describe the type of accomodations requested/needed:

Applicants requesting ADA examination accomodations must submit medical and/or psychological documentation from a qualified professional below:

Drop files here or

Max. file size: 64 MB.

Final Steps

Acknowlegement*

I do hereby make a voluntary application for certification from IVAPM. I certify that the information given by way of this application is true, honest, and completely represents me. I understand and agree that if I am awarded Certification, I will conform to all applicable local and governmental regulations and will conduct my professional behavior consistent with the highest standards of professional conduct, as established in the Code of Ethics of the IVAPM, as well as those codes of ethical conduct relating to my specialty. I agree to abide by the regulations of the IVAPM and I recognize that failure to do so may result in suspension or revocation of my standing within this organization. I understand that any credential by the IVAPM does not in and of itself imply or grant license to practice in any country or state. Furthermore, I understand and agree that the IVAPM and its affiliates assume no responsibility for my action or activities. I practice at my own risk and hereby release the IVAPM from any and all liability from any practice decision I make in the practice of veterinary pain management.

Application Payment*

DVM Payment URL: https://ivapm-membership.site-ym.com/store/viewproduct.aspx?id=21150348
Tech Payment URL: https://ivapm-membership.site-ym.com/store/viewproduct.aspx?id=21150411

Please utilize the correct URL to pay your CVPP Application fee and then select the correct radio button above indicating you have paid.

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