Colorado Association of Certified Veterinary Technicians Certification / Membership Renewal Application July 1, 2014 June 30, 2016

Colorado Association of Certified Veterinary Technicians Certification / Membership Renewal Application July 1, 2014 June 30, 2016 CACVT is the governing body and professional association for Certified Veterinary Technicians in the state of Colorado. Please fill out one application per person * All information must be filled in for application to be accepted PLEASE PRINT LEGIBLY Name Mailing Address City State Zip Code Email Phone AVMA-accredited Veterinary Technology Program Date Graduated State in which VTNE was taken Date Tested Active Association Membership: Certified Veterinary Technician* (This application certifies you within the July 1, 2014 June 30, 2016 certification cycle): Active Association CVTs belong to both branches of CACVT (Certification & Association). Members will be certified in Colorado and belong to the Professional Association, receiving all benefits of membership, including access to members only information, voting rights, discounts on CE and services, and much more. Active CVT - $153.00 For individuals renewing certification (Active Certification of $128.00, plus $25.00 late fee) Required Documentation: 1. 2014-2016 Renewal Application 2. Complete CE Submission Form (attached below) 3. Payment Return completed Application WITH the required documentation AND payment to: CACVT 191 Yuma Street, Denver, CO 80223 Fax: 303-318-0651 Incomplete Applications will not be accepted. A $25.00 service charge will be added to all returned checks. A certification card will be mailed to you within 10 weeks. * Must meet continuing education (CE) requirements to maintain certification. Renewal fees and minimum amount of required continuing education must be received by June 30 th of each even year to maintain Colorado Certification.

of 7 Payment Information Check enclosed (payable to CACVT) OR Charge to my Visa MasterCard Account number Expiration Date 3-digit security code Billing address City/State Billing zip code Name on card Demographic Information Demographic information is required. CACVT is unable to assess industry trends for the improvement of this profession without solid demographic information from ALL members. If this section is not filled in, your application is incomplete. Date of birth: Gender: Female Male Race/Ethnicity American Indian or Alaska Native Hawaiian or Other Pacific Islander Asian or Asian America Black or African American Hispanic or Latino Non-Hispanic White Caucasian Marital Status Married Single Unmarried, cohabitating with a partner Credentialing Status Veterinary Technician Specialist Certified Veterinary Technician Uncertified Technician / Assistant Student (in AVMA Accredited Program) Employment Status Employed Full-time Part-time Relief Self-employed Out of work for more than 1 year Out of work for less than 1 year Homemaker Student Retired Unable to work Employment Setting Clinical Small Animal GP Large Animal Mixed Practice Livestock Exotics Shelter Zoo University Specialty * Which: Other Practice Management Academia Industry Nonprofit Self-employed Other Salary Less than $20,000 $45,000 to $49,999 $20,000 to $24,999 $50,000 to $54,999 $25,000 to $29,999 $55,000 to $59,999 $30,000 to $34,999 $60,000 to $64,999 $35,000 to $39,999 $65,000 to $69,999 $40,000 to $44,999 >$70,000 Education Completed High School Associate degree (for example: AAS) Bachelor's degree (for example: BA, BS) Master's degree (for example: MA, MS, MEd, MBA) Professional degree (for example: MD, DDS, DVM, JD) Doctorate degree (for example: PhD, EdD)

of 7 Colorado Association of Certified Veterinary Technicians Governance Directory As the governing body for Certified Veterinary Technicians in Colorado, CACVT maintains a public list of Certified Veterinary Technicians in good standing in the state of Colorado. This list is primarily used by employers to verify Certification Status. Colorado Veterinary Medical Association Directory Certified Veterinary Technicians in Colorado may also appear in the CVMA Directory (name, city and state only). All individuals associated with CACVT are responsible for updating contact information, including mailing address, email address, phone, and change of name, in the event that a change occurs. CACVT is not responsible for mail or email not reaching an individual, or inaccuracies in status, on account of contact information not being updated or a name change not being disclosed. As a Certified Veterinary Technician, you are responsible for maintaining and tracking your Continuing Education, and renewing your application with the CACVT by June 30th of each even year, in order to maintain Active Certification Status. CACVT requires that you submit a completed CE Submission Form that accounts for all required CE, along with your application and payment for renewal. Please do not submit partial/incomplete CE Submission Forms to the office; they will be disregarded. Please do not send collateral information, or proof of attendance certificates. CACVT will request these items if you are audited in the CE audit process. As a CVT, you are responsible for keeping and maintaining these records. If in the event of a CE audit, you are unable to provide this support documentation, further action will be taken and your certification will be in jeopardy. Association dues may be deductible as a business or professional expense, to the extent allowable by law. Please consult a tax accountant. Association dues are not deductible as a charitable contribution for tax purposes. Continuing Education Form Details Please list the continuing education events attended July 1, 2012 June 30, 2014 using this form. CE acquired outside of these dates is not applicable for this renewal period. Extra CE acquired during this period does NOT carry over into the next renewal period. REQUIRED: 20 CE Credits (at least 8 of which must be from the technical category) Submit CE Submission Form once all 20 CE hours are obtained as part of your renewal packet. DO NOT submit partial CE Submission Forms to the office, and do not submit a CE Submission Form independent of your renewal packet. They will not be accepted. As a CVT you are responsible for tracking your CE hours and submitting a complete form, with all hours met, upon certification renewal. DO NOT submit proof of attendance at this time. If you are randomly selected from the database for CE audit, then you will be asked to provide proof of attendance. As a CVT you are responsible for retaining proof of attendance for your own professional records. If you are audited and cannot provide proof of attendance, your certification status will be affected. Please see CE Guidelines under Continuing Education on the CACVT website if you have questions regarding catagorizing or eligibility of a particular CE lecture or event. Return to CACVT after all 20 hours are completed as part of your certification renewal packet; CE forms will not be accepted without this complete renewal packet

of 7 COLORADO ASSOCIATION OF CERTIFIED VETERINARY TECHNICIANS CONTINUING EDUCATION 2012-2014 (Please Type OR Print Legibly) CE HOURS SUBMITTED: # Technical + # Supportive = TOTAL CE