Test Application Form

Applicant’s Name ______________________________Titles ____________________

Specialty: Cardiology Large Animal Neurology Oncology Small Animal

Home Contact Address ___________________________________________________

City ____________________ State __________ Country __________ Zip Code _____

Home Phone _________________________ Cell Phone _________________________

Work Contact Place of Employment ________________________________________

Employer Contact (you boss) ______________________________________________

Address _______________________________________________________________

City ____________________ State __________ Country __________ Zip Code _____

Work Phone ___________________________

Email address ___________________________________________________________

Please use my (select one) home work as my primary contact

Please let us know if we can share your contact information with the other examinees

YES NO

Is this a retest? YES NO

Examination Fee Schedule: General & Specialty Exam $150

Please send appropriate examination fee along with this application to:

AIMVT

PO Box 75221

Seattle, WA 98175-0221

Deadline for examination fee submission is February 1^st of testing year