Part 1: Applicant Information
Name of Applicant (First, Last)
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Part 2: Reference Information
Name of Person Providing a Reference (First, Last)
Title/Position
Employer
Phone
Email
Business Address Line 1
Business Address Line 2
City
State/Province
Zip Code
Country
Are you an IVFSA Member?
Yes
No
If yes, what is your IVFSA Membership Level?
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Part 3: Knowledge of the Applicant
Please describe your knowledge of the applicant, including: working relationship; training in veterinary forensic sciences; percentage of time devoted to veterinary forensic sciences; and years practicing veterinary forensic sciences.
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Part 4: Ethics
To the best of your knowledge, has the applicant ever been censured for unethical conduct or procedure? (If yes, please explain.)
Yes
No
If yes, please explain.
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Part 5: Recommendation
Do you recommend with qualification that the applicant be approved? (If no, please explain.)
Yes
No
If no, please explain.
Does your recommendation require any qualifications? (If yes, please explain.)
Yes
No
If yes, please explain.
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Part 6: Comments
Please use this space for additional comments regarding the applicant.
Signature
*
Please provide an electronic signature in the space provided. (Note: If you're using a mouse, hold down the left mouse button to sign. If you're on a touch screen device, use your finger or a stylus to sign.)
Date of Signature (MM/DD/YYYY)
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