Name of Applicant Referencing* First Last Applicant Registration Number (if known) Evaluator's Name* Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred method of contact* Phone Email Email* Enter Email Confirm Email Phone*Institution* How long have you known the applicant?* Less than 1 yr 1-3 yrs 3-5 yrs 5-10 yrs More than 10 yrs Position* In what capacity do you know the applicant?* I would like to... Upload a letter of recommendation Fill out the online recommendation form Upload letter of recommendation*Accepted file types: doc, docx, pdf, Max. file size: 2 MB.The purpose of this form is to assist the IVAPM in evaluating applicant’s experience in animal pain management and research. Please rate on a scale of 1 (Poor) to 5 to (Excellent) the applicant's knowledge, experience, and skills as they relate to his/her professional activities in veterinary pain management and research.AssessmentApply Principles of Anatomy & Physiology 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Perform Patient Assessment 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor TreatmentDevelop Treatment Plan 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Implement Treatment Plan 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Implement Specific Treatment Modalities 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Assessment of Treatment Outcome 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Ethical/Professional/Legal/BusinessEducate Clients, Practice Staff 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Practice Ethically, Professionally, and Legally 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Incorporate Outcome Measures 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor Comment on the applicant’s strengths and weaknesses in relation to pain management or pain research.*Additional CommentsUpload copy of your signature*Accepted file types: jpg, png, gif, pdf, psd, bmp, tif, Max. file size: 2 MB.Please upload a copy of your signature. Acceptable file extensions include jpg, png, gif, pdf, psd, bmp, or tif.CAPTCHA