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AABP Manage Your Rural Practice for Success Workshops

 

Individual applications cannot be saved on the application site prior to submission. For example if you partially complete this application with the idea of returning to the site to complete it at a later time your application will not be saved.

All fields are required, and must be filled in before submitting the application.

First Name:
Last Name:
Address:
City:
State/Province:
Zip:
Office Phone:
Cell Phone:
Email:
Are you a US Citizen?
Yes        No

Veterinary Information

Are you a licensed veterinarian?
Yes
No
List states where you are licensed:
Are you an owner or associate?
Owner Associate
If not an owner, are you in the process of becoming an owner?
Yes
No
Will you have access to practice financial records (categories and amounts for income and expenses for past three years) for use in the workshop?
Yes
No
Counties (and states) served by veterinary practice:
Year graduated from veterinary school:
Veterinary School:
% Food animal income in practice: :
Do you presently serve in or adjacent to a VMLRP areas based on data through 2019?
Yes
No
Please list VMLRP counties and states, if none type NONE:

Note VMLRP data is available for each state at https://nifa.usda.gov/vmlrp-shortage-situations

Are you planning to offer services in a VMLRP area (based on above data through 2019)? Yes
No

If you are not serving in or planning to serve in one of the VMLRP areas, you may write a brief argument that you are serving in a rural area that is lacking in a shortage area, even if the area is not officially designated by the VMLRP as such. Shortage in this instance may be defined as an area where the veterinary needs of the clients are not being addressed to the fullest extent, using presently available technology.

Note: Click the paste text to paste text.

Workshop Registration

Please prioritize the workshops that you are applying for: February 27-29, 2020
March 19-21, 2020
A limited number of applicants may bring a second person from their practice such as a managing spouse, office manager or other veterinarian, to the workshop for a fee of $250.
Note there will not be a stipend for the second person.
Would you be interested in bringing a second person from your practice to the workshop? Yes
No
Additional Persons Name from your practice:
Please initial that you agree to the following:

"Are you willing to commit to each two-day session this year, attend the second two day session next year, completing the required pre-work for the classes and several conference calls?"

Initial:
Please confirm the following by initialing:

"I certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information given may be investigated and that any false representation is sufficient cause for rejection of the application."

Initial:

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Comments/Suggestions/Problems should be directed to Steve Johnson

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