ACT Vet Board - Request for Letter of Professional Standing

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ACT Veterinary Surgeons Board
Send the completed form to:
ACT Veterinary Surgeons Board
GPO Box 158
Canberra ACT 2601
Ph: 02 6207 0012
Fax: 02 6207 6148
Email: [email protected]
REQUEST FOR LETTER OF PROFESSIONAL STANDING (LOPS)
VETERINARY PRACTITIONER DETAILS
Name:
Registration No:
Address:
Suburb:
State:
Phone:
Postcode:
Email:
Qualifications:
Graduated
from:
Country:
Year:
WHERE TO SEND LOPS (PLEASE TICK)
New South Wales
Victoria
Queensland
Tasmania
United Kingdom
South Australia
Western Australia
Northern Territory
New Zealand
Other
Board Name
Address
Email
1 of 2
12 Wattle Street, LYNEHAM ACT 2602 : GPO Box 158, CANBERRA ACT 2601
Tel: 02 6207 0012 : email: [email protected]
PAYMENT DETAILS
See fee schedule - no GST applies.
Please tick appropriate box
Cheque attached
Note: please make cheque payable to; Veterinary Surgeons Board of the ACT
Money order
attached
Credit card payment
Total Amount
paid
$
Name on card
Card Number
Card type
Expiry Date
Visa
MasterCard
Signature
2 of 2
/
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