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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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