MAV Registration April 2020 Medical Acupuncture for Veterinarians Registration April 2020 Step 1 of 3 - Basic Information 33% Medical Acupuncture for Veterinarians Program - Fort Collins, Colorado. Course size is limited to ensure high-quality instruction for all participants. Registrations are accepted from qualified applicants on a first-come basis until we reach maximum enrollment. 2020 Spring Clinical Intensive Dates April 20 - 25, 2020 Track (PLEASE NOTE SPECIFIC DATES) Dual Track 20 - 25, 2020 Single Track Canine/Feline 20 - 24, 2020 with optional Exotics day April 25, 2020 Single Track Equine/Farm Animal 21 - 25, 2020 Basic InformationName* First Last Preferred Name on BadgeTitle DVM MRCVS VMD Veterinary Student Name for Certificate of Completion (including degrees i.e. Jane Doe, DVM, cVMA)*Practice Focus (check all that apply) Large Animal Small Animal Equine Exotic Other If 'Other,' please specify your practice focusVeterinary College Graduated From*Year of Graduation*State Where LicensedLicense Number (upload a copy of your license below)Upload a copy of your current veterinary license or letter from your school showing that you are a student in good standing or a faculty member that does not require a veterinary license to teach and practice. You will be enrolled in the course once this has been received, reviewed, and accepted.Accepted file types: pdf, jpg, png, .Formats accepted are pdf, jpg, png. The file will upload when you submit the form.How did you hear about this course (check all that apply)* Website Friend/Co-worker School Conference Other Please indicate the school, conference or explain other:Interactive Medical Acupuncture Anatomy - Preferred version: (note the Kindle version does not include the DVD with rotatable model.)* Hard Copy Kindle All student applicants must be members of SAVMA and provide proof of professional liability insurance. Please upload below.Accepted file types: pdf, jpg, png.Formats accepted are pdf, jpg, png. The file will upload when you submit the form. Contact InformationMailing Address (preferred for course material)* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Is this address your home or work address? Home Work Work PhoneCell Phone*Email Address (preferred for course material)* Program SelectionCheck the selection below that applies to you*VeterinarianFourth-Year Veterinary Student §§ Fourth-year students must provide a letter verifying that they are a student in good standing from the veterinary school's Dean's Office.Veterinarians - April 2020 Tracks - Please choose courseApril 2020 Dual Track: 12 Modules of MAV - $9,700April 2020 Single Track: 10 Modules of MAV - $8,700Please choose your single track preferenceEquine/Farm Animal TrackCanine/Small Animal TrackVeterinary Students - April 2020 Tracks - Please choose courseApril 2020 Dual Track: 12 Modules of MAV - $9,100April 2020 Single Track: 10 Modules of MAV - $8,100Please choose your single track preferenceEquine/Farm Animal TrackCanine/Small Animal TrackSingle Track Canine/Feline - Exotics Day (additional day)Veterinarian Exotics day - $550Veterinary Student Exotics day - $450Dual Primary Focus - this will determine your scheduleEquine/Farm Animal adding in Canine/FelineCanine/Feline adding in Equine/Farm Animal Terms and Conditions Returned Check Policy There will be a $35 fee for checks returned for insufficient funds and course will be suspended until payment clears. Cancellation Policy CURACORE VET reserves the right to cancel the course or any clinical intensive(s), and to change the dates or venue of the intensive(s). A full refund will be given if the course is cancelled. No refunds will be granted once you have started the course. I understand that by submitting this registration form and the course registration fee to reserve a seat in the upcoming MAV course that the course registration fee is non-refundable per policy. I understand that if I cannot attend the specified Clinical Intensive that there are fees that will occur to change to the next available Clinical Intensive. I have read, understood, and agree to the terms and conditions contained herein. I further understand that by signing below, I have reviewed and agree to the course curriculum, subject to such changes as may be approved by CURACORE VET. Deferment: Students who wish/need to defer to the next available Clinical Intensive, greater than 60 days prior to the Clinical Intensive date, are assessed a $700 deferment fee. Students who wish/need to defer less than 60 days prior to the Clinical Intensive will be assessed a $1,000 deferment fee.Type your name in here to indicate that you agree to the terms outlined above*End User Agreement* I agree. Note: By clicking "I Agree" you acknowledge that you have read and agree to the terms set forth in the end user agreement. You must read the linked document and check the box above to continue with the form.Additional ItemsDietary RequestsVegetarianVeganGluten Free/SensitiveOtherIf 'Other,' please describe dietary requestSign Up for Our Course Announcements Sign me up! PaymentsCoupon Code Will you be paying by credit card, check or wire transfer?*Credit CardCheck in US dollars (mail to CURACORE VET, 905 S Summit View, Fort Collins CO 80524)Wire Transfer (contact Sharon Sherwood at firstname.lastname@example.org for specific instructions) Note: If paying by credit card, you will be asked to enter your billing address separately when checking out. Total $0.00 If paying by check, please make payment to "CURACORE VET" and mail to: CURACORE VET 905 S Summit View Dr Fort Collins, CO 80524 For your security, please send payment with tracking information. Questions? Contact us at email@example.com or 970-818-0851.NameThis field is for validation purposes and should be left unchanged.