Professional History and Experience Information

Full Name: Email: Phone: Address: Street City State Zip Present Occupation/Title: You provide anesthesia primarily to: Are you a graduate of an AVMA accredited veterinary technology program? School: Graduation Date: Pass date of VTNE: NAVTA membership number:

International Candidates : (List your current certification and license information)

LIST YOUR EMPLOYMENT HISTORY 6/1/2010 till 6/1/2015

Work History from 6/1/2010 to 6/1/2011 Start Date: End Date:

Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

Work History from 6/1/2011 to 6/1/2012 Start Date: End Date:

Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

Work History from 6/1/2012 to 6/1/2013 Start Date: End Date:

Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

Work History from 6/1/2013 to 6/1/2014 Start Date: End Date:

Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

State License # Original Date

List each state in which you hold an active license to legally practice as a veterinary technician INDICATE original date of credentialing Has your license ever lapsed or been inactive? Explain:

Professional History and Experience Information

LIST YOUR EMPLOYMENT HISTORY 6/1/2010 till 6/1/2015 – Page Two

Work History from 6/1/2014 to 6/1/2015 Start Date: End Date:

Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

The area below is for SECONDARY POSITIONS held during the same year as a primary job ora change of primary employment mid-year from June 2010 to June 2015.

ONLY FOR SECOND POSITION IN YEAR Start Date: End Date: Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

ONLY FOR SECOND POSITION IN YEAR Start Date: End Date: Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

ONLY FOR SECOND POSITION IN YEAR Start Date: End Date: Name of Practice/Institution: Type of Practice:

Supervisor name: Contact phone: Contact email:

Regular hours worked per DAY: # Days worked per Week: Average hours of work day spent providing primary anesthesia care: (maximum of 2000 hrs. / year is accepted)

For AVTA Credentials Committee use only:

Total # of CREDENTIALED HOURS: _______

Total # of ANESTHESIA HOURS: _______