Don Low-CVMA Practitioner Fellowship Preliminary Application
20 Days during Academic Year
2016–2017
Please fill out electronically - Handwritten applications will not be considered
1.
Name:
2.
Address:
3.
Preferred contact:
4.
Day Phone
Home
Work
Night Phone
Home
Work
E-mail
Home
Work
In what service are you applying for a fellowship?
(please highlight one)
Anatomic Pathology
Anesthesia
Behavior
Cardiology
Comparative Theriogenology
Clinical Pathology
Equine Integrative Sports Medicine
Laboratory Animal Medicine
Livestock Medicine & Surgery
5.
Have you previously applied? Yes
Medical Oncology
Microbiology & Parasitology
Neurology/Neurosurgery
Ophthalmology
Shelter Medicine
Small Animal Emer & Critical Care
Small Animal Abdominal Ultrasound
Small Animal Internal Medicine
Small Animal Soft Tissue Surgery
No
If so, in what area(s)?
6.
Veterinary degree
School/College
Year Graduated
7.
What local/professional associations are you a member, if any?
8.
If employed, Name of Owner/Supervisor:
Are they aware of and supportive of your application? Yes
No
Comments:
9.
Current Practice:
Name
Address
Type of Practice: Small Animal
Birds
Your Practice Position?
Equine
Other
Owner
Food animal
Mixed
(describe)
Partner
Employee
10.
List the jobs you have held since becoming a veterinarian:
11.
Provide a brief description of your current practice activities:
12.
What are your goals for the fellowship?
13.
How do you plan to share your experiences with the profession at
a local and/or state level?
Other?
14.
Are there additional reasons you should be selected as a finalist that
you want the Committee to consider?
15.
List additional degrees, certifications, and experiences, in your area
of interest, that might relate to your Fellowship candidacy (add additional
pages if necessary):
16.
List relevant continuing education accomplished in your area of interest, including
when, where and who taught the CE.
17.
Please provide the names and contact information of three professionals
who can serve as references:
a)
Name
Address
b)
Name
Address
c)
Name
Address
18.
Email
Phone
Email
Phone
Email
Phone
Signature ________________________________ Date
Mail completed preliminary application to arrive by May 6, 2016 to:
Jan Harlan - jdharlan@ucdavis.edu
Veterinary Medical Teaching Hospital Director's Office
School of Veterinary Medicine
University of California
Davis, CA 95616
Use additional pages to type answers if necessary
________________