Free 51115.FH11 - Indiana

APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAMS FOR VETERINARIANS AND VETERINARY TECHNICIANS
State Form 51115 (1-06)

INDIANA BOARD OF VETERINARY MEDICAL EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-2054 E-mail: [email protected]

DATE RECEIVED (month, day, year) APPROVAL DATE (month, day, year) CONTINUING EDUCATION HOURS GRANTED
DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS. SPONSORING ORGANIZATION
Name of sponsoring organization Address (number and street or post office box) City Telephone number (daytime) Fax number E-mail address State ZIP code Website

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) PROGRAM COORDINATOR

Name(s) of program coordinator(s) Mailing address (number and street or post office box) City Telephone number (daytime) Fax number E-mail address State

Title

ZIP code

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) PROGRAM TO BE OFFERED

Program title Program date(s) Location of program (city and state) Number of Continuing Education hours requested Is this program for:

One Program Multiple Programs

Veterinarians

Veterinary Technicians TYPE OF PROGRAM

Both

Conference Seminar Short Course

Institute Workshop Videotape

Special Training Program Satellite Program Other

OBJECTIVES List the objectives for the continuing education course.

CONTENT OF PROGRAM Please provide the Board with a brief summary of the content of the program below. Attach a copy of the program outline or brochure with time frames to this application.

LECTURERS Attach curriculum vitas and resumes of all lecturers showing education and professional background. NAME OF LECTURER ACADEMIC AND PROFESSIONAL BACKGROUND

ADMINISTRATION 1. Who will provide participants with a record of attendance and retain records of attendance by participants for four (4) years from the date of the program? 2. Does the Record of Attendance that will be awarded to the veterinarian or veterinary technician state the following: 1. Sponsor of the program? 2. Name of the program? 3. Date of the program? 4. Number of continuing education hours awarded? NOTE: Each participant must be provided a record of attendance. Yes Yes Yes Yes No No No No

ADDITIONAL INFORMATION REQUIRED 1. Have you enclosed the following items: a. One (1) original and one (1) copy of your application for continuing education approval. b. One (1) original and one (1) copy of the program outline or brochure with time frames. c. One (1) original and one (1) copy of the curriculum vitas or resumes of all lecturers. 2. Have you applied for continuing education approval with any other entity? If yes, please specify: Yes Yes Yes Yes No No No No

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of program coordinator Date signed (month, day, year)