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AVA CVP Admission Form

Application

First name*

Middle name(s)

Family name*

Preferred name

Email*

Alternate email address

Phone (Mobile)*

Phone (work)

Phone (home)

Address Line 1

Address line 2

Suburb

State

NSW

ACT

QLD

VIC

SA

TAS

NT

WA

Postcode*

When do you wish to commence your studies in the AVA CVP Education Pathway

January 2024

July 2024

January 2025

Do you hold current membership with the AVA?* -- Select an option -- Yes No

AVA membership number

Are you a current member of the ASAV special interest group? -- Select an option -- Yes No

How many years have you been practicing as a small animal practitioner?

Please include evidence of your veterinary science qualification

Which state/territory are you currently registered as a veterinary surgeon? (choose all that apply)

NSW

QLD

VIC

SA

WA

TAS

ACT

NT

What is your Primary Vet Board Registration Number?

Course fees associated with the AVA CVP Education Pathway will be payable by: -- Select an option -- My employer (please include your employer’s details below) Myself

Company Name Responsible for Payment

I approve for the AVA to update any of the information outlined below in my records with them.

Yes

No

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