APPLICATION FORM

 

VISITING PRACTITIONER PROGRAM

 

CUMMINGS SCHOOL OF VETERINARY MEDICINE

AT TUFTS UNIVERSITY

 
NAME____________________________________________________ TITLE ______________________________________________
ADDRESS  _____________________________________________________________________________________________________
SCHOOLS ATTENDED AND DATES _________________________________________________________________________________
DEGREE(S) and DATE(S) OBTAINED___________________________ PHONE _____________________________________________
FAX_____________________________________________________ EMAIL ______________________________________________
DESIRED ARRIVAL DATE____________________________________ DESIRED DEPARTURE DATE____________________________
DEPARTMENT(S) /SPECIALITIES YOU WISH TO VISIT, DESIRED PROGRAM, DESIRED MENTOR, IF ANY (USE EXTRA PAGE IF NEEDED:

                                                                                                                                                                                                                          
                                                                                                                                                                                                                          
                                                                                                                                                                                                                           
                                                                                                                                                                                                                           
I HAVE ENCLOSED THE FOLLOWING DOCUMENTS:   
____Rabies vaccination proof or titer ____ Two letters of reference
____Proof of Health Insurance ____Curriculum Vitae
____Letter of Intent ____$25 Application Fee (non-refundable)
___Negative TB test proof
 SIGNATURE OF APPLICANT____________________________________________________________________________________

Please submit this form, accompanying documents, and check for nonrefundable application fee of $25, made out to Trustees of

Tufts University for $25, to:

Cummings School of Veterinary Medicine at Tufts University

Office of Continuing Education/Conference Planning

200 Westboro Road

North Grafton, MA 01536