※Surname:

※Name:

Work Address:

Work Telephone:

Work Fax:

※Work E-mail:

Home Address:

Home Telephone:

Home Fax:

Proposed Period of Residency (Give exact dates),
Start: 　 Finish:

Veterinary School Attended:

Date of Graduation:

Degrees and Other Qualifications:

Countries in which you are Registered/Licensed to practice Veterinary Medicine:

AiCVD ALTERNATE ROUTE RESIDENT REGISTRATION FORM:
To Be Completed By The Resident

Pre-Residency Training

Give name(s), address(es), telephone number(s) of place(s) of employment, type of training, name(s) of veterinarian(s) responsible for training and date(s) of training:

Give the Names of All National and International Veterinary Medical Associations
(e.g. Japanese Society of Veterinary Medical Association) to which you belong

Have you ever been required to appear before a veterinary disciplinary committee or equivalent on questions of competency or ethical behaviour ?

(Please tick. If yes, attach full details)　　　　　 Yes　　　　 No

1) Facility: Give details of the dermatology programme. Are small animals, large animals and exotic/small mammals seen? Are large/exotic animals seen somewhere else? Describe the consulting room, the laboratory and the equipments available to the residents for the daily clinical activity. Is there both a first opinion and referred case clinic or a referred case clinic only?

2) Clinical Training & Supervision. Describe the supervised and non-supervised time spent in the clinic. Describe the caseload in small, large and exotic animals.

3) Basic Science and Theoretical Clinical Training. Describe how it is intended to teach the basic science, structure and function and immunology of dermatology.

4) Structure & Function and Clinical Dermatology. Describe how much time is spent in reviewing books (e.g. Small Animal Dermatology, Equine Dermatology, Human Dermatology), attending lectures at university, etc.

5) Dermatopathology Training. Is the dermatopathology training done by a Pathology Diplomate, persons with other qualifications in Pathology or a Dermatology Diplomate? Has the Resident access to a slide archive? Where is the training done?

6) Research Project. Which facilities and financial support are available to allow the Resident to perform a research project?

7) Teaching & Presentations. Would the Resident be involved in lecturing to students, lay people (e.g. breeders), nurses, or colleagues? The presentation of case reports or clinical/retrospective studies must be encouraged at local, national and international meetings.

8) Continuing Education. Would the Resident get financial help and time to attend national, international meetings and workshops?