CPD Summary Sheet

Continuing Professional Development Summary Sheet

The IVCA reserves the right to audit any and / or all applications.To complete this form please print legibly the below details:

Title:
Name
Address	Address
Phone
Fax
Email
Website
Professional degree
IVCA membership number
	IVCA Approved CPD (20 hours minimum of the total 30 hours required) Independent Learning (10 hours maximum of the total 30 hours required) Eg. Reading articles, accessing the Internet, practice-based research, Attending professional courses, conferences, seminars (i.e. chiropractic courses for veterinarians or veterinary courses for chiropractors), Observing another IVCA certified member of either profession out in practice

IVCA Approved Course Provider	IVCA approved course/seminar name	Date	Hours

Description	Date	Hours

I confirm that the above details are correct and that I agree to adhere to and abide by the IVCA code of conduct and standard of proficiency.

Date_______________ Signed ___________________________________________