Form for Registration of a Fellow of the Academy of Veterinary Dentistry for the AVDC Examination Introduction The Academy of Veterinary Dentistry and American Veterinary Dental College are now in an Alliance. Under the terms of the Alliance Agreement, veterinarians who became Fellows of the Academy prior to 2014 and who are in good standing in the Academy but are not diplomates of the College have a onetime opportunity to apply for registration as a candidate for the AVDC examination without having to complete any additional AVDC training program or credentials requirements. As approved by the Academy Board of Directors and endorsed by the College Board of Directors, Equine Fellows of the Academy are eligible to take only the AVDC Equine examination, and Small Animal Fellows of the Academy are eligible to take only the non-species specific AVDC examination. AVDC examination candidates who became eligible via the Academy Fellow route will be eligible to take the appropriate AVDC Diploma examination as for any other AVDC examination candidate. The deadline for applying for this opportunity is December 31st, 2014, though for planing purposes for the 2015 AVDC examination, an earlier submission would be appreciated. Please also submit the separate form regarding your plans for the 2015 examination. This signed form can be mailed with the application fee payment to the address at the end of this form, or a scanned copy of the signed form can be submitted either as an email attachment or as a file uploaded to a DMS Miscellaneous document; if an electronic copy of the form is submitted, it must be accompanied by a completed and signed credit card payment form. AVDC prefers submission of a mailed form and check in US$ made out to ‘American Veterinary Dental College’ and paid from a US bank account. Completing this form and registering as an AVDC candidate does not change your status as an Academy Fellow. By signing this form, I acknowledge and agree to or accept that: 1. An Academy Fellow who requests registration as a candidate for an AVDC examination program will be subject to all AVDC examination requirements, which are stated in the Examination Information file (available at the http://www.avdc.org/traineeinfo.html). 2. My registration as an AVDC candidate grants me three attempts at the examination in a six year period, and that the AVDC Board will not grant exceptions to this three-attempt rule unless a change is made in AVDC policy. 3. The AVDC examination from 2015 onwards will consist of two parts, given separately. Part 1 is a Multiple Choice Question examination (or combination Written/Bench multiple choice question examinations). Part 2 is a Practical examination. Entry to Part 2 will be limited to candidates who have passed the Part 1 examination. I understand that if I fail Part 1 three times, I will not be permitted to take the Part 2 examination, and will no longer be an AVDC examination candidate. 4. Failing the AVDC examination will not change my status as a Fellow of the Academy. 5. AVDC will check my status as an Academy Fellow, and that this application will be accepted by AVDC only if I am in ‘good standing’ in the Academy records. 6. I have checked my personal information in the Veterinary Dental Document Management System (DMS) and have made corrections or updates as appropriate, and I understand that my Academy DMS information, including my UserName and PassWord, will automatically transfer to my AVDC registration in DMS. 7. I will abide by the following AVDC Ethical and Professional Standards: a. AVDC endorses the AVMA Principles of Veterinary Medical Ethics and the American Board of Veterinary Specialties statement that members of ABVS-recognized colleges are to “Demonstrate unquestionable moral character and ethical professional behavior”. b. AVDC limits its membership to veterinarians who maintain high ethical and professional standards, both in their work as specialists in veterinary dentistry and in tasks conducted on behalf of AVDC (such as assignment to a committee or service as an officer or Board member). When a member is acting on behalf of AVDC, “high professional standard” requires adherence to current standard operating procedures approved by the AVDC Board of Directors, including AVDC’s Confidentiality Policy. c. AVDC candidates and Diplomates are to promptly notify the AVDC Executive Secretary of any legal action or judgment by a criminal court or investigation by a State Board of Veterinary Medical Examiners relating to their professional activity, current or past, or of any other circumstances that may demonstrate or imply inappropriate ethical or professional activity. Whether based on information forwarded by a member or obtained from a third party, the AVDC Board of Directors shall investigate such circumstances, and shall apply Article IV, Section 4 of the AVDC Constitution (“Removal of Membership”) when necessary. (If there are any past circumstances of this nature in your case, briefly report the issue and the resolution and date in a note accompanying this form; this will be held in strict confidence). d. I will abide by the AVDC Policy on Use of Specialty Titles stated below: AVMA Principles of Veterinary Medical Ethics: It is unethical for veterinarians to identify themselves as or in any way imply that they are members of an AVMA-recognized specialty organization until such time as a diploma certification has been awarded. AVDC has adopted the Guidelines for Use of Specialty Titles, prepared by the American Board of Veterinary Specialties of the American Veterinary Medical Association. Acceptance as a candidate for the AVDC examination does not grant the candidate the right to make any mention of AVDC status until the candidate has passed the examination. 8. Fee and dues: a. I enclose payment of US$1,250. This consists of the 2015 examination fee ($1,100, no matter whether Parts 1 and 2 are taken or just Part 1) and a $150 candidate registration fee. I understand that the $1,100 examination fee will be refunded on request if I elect to defer taking the examination in 2015. I enclose payment in the form of a check made out to “AVDC” or as a completed Credit Card Payment form (only for non-US registrants). I am aware that the examination fee for 2016 will consist of separate fees of $1,100 for the Part 1 Multiple Choice Question examination and separate fee of $1,100 for the Part 2 Practical examination. b. Upon passing the AVDC examination, I agree to pay the annual AVDC membership dues, at the rate set by the AVDC Board, in order to remain ‘in good standing’ as an AVDC member. 9. Certificate: I accept that the AVDC Diploma remains the property of the College, and that it is issued for a limited to a 10 year period upon successful completion of the examination process, as required by the American Board of Veterinary Specialties. I understand that to renew my diploma, I will be required to complete the AVDC Renewal of Certification process. Applicant name: Date I became an Academy Fellow Category of Academy Fellow Applicant Signature: Equine Small Animal (delete as necessary) Equine and Small Animal (if both, state whether you wish to take the AVDC Equine Examination or the AVDC Non-species-specific Examination (the exam that the Small Animal Fellows are eligible for). Date: This form is to be submitted as a signed document and is to be sent with the application fee to: Colin Harvey, Executive Secretary, AVDC 622 Maple Court, Haddonfield, NJ 08033, USA. If you have any questions about this form or related items, send an e-mail message to ExecSec@AVDC.org. AVDC Exec Sec action: Academy status and registration date checked. Credentials Committee chair Review: Additional information requested. Approved.