ACZM 1st Time Credentials Application

Application materials must be submitted electronically by March 31st at 11:59 PM North American Central Daylight Time (UTC-5) via this webform.

Please note, this form must be completed in one sitting - you cannot save it, close the window, and come back to it later. We suggest downloading the checklist (https://docs.google.com/document/d/1XQN4_rmnshyV-OR2Mvb2u5vv_nEi26WR/edit?usp=sharing&ouid=111655243818225329655&rtpof=true&sd=true) to be certain you have all required documentation before starting to fill out the application. If you are still in a residency program at the time of application, your certification of completion can by uploaded once completed this summer.

The ACZM Secretary (secretary@aczm.org) will check all applications for completeness and reach out with any questions or concerns.

Overview of the Documents Needed for the Submission of Application Materials

YOU WILL WANT ALL DOCUMENTS AVAILABLE TO YOU BEFORE YOU BEGIN COMPLETING THE APPLICATION. YOU CANNOT SAVE AND COME BACK AT A LATER TIME.

-Complete application below.

-Residency Route or Experience Route Documentation.

-Documentation of completion (scanned residency certificate) of an ACZM-approved training program or completion of the experiential pathway. If you are still in a residency program at the time of application, your certification of completion can by uploaded once completed this summer.

-Current Curriculum Vitae with the required information.

-Scanned copy of current license(s) to practice veterinary medicine.

-Electronic PDF documents of each of your three (3) first-authored publications to be considered in the application. For papers “In Press”, include a copy of the accepted manuscript and a letter(s) from the journal editor(s) indicating that publications have been fully and unconditionally accepted.

-Three (3) electronic letters of reference. One letter must be from an ACZM Diplomate. Letters of reference should be submitted at this link: https://app.smartsheet.com/b/form/215d94b2b3b8423ebaf94b8a3ef779f4

-Electronically signed and dated legal statement

-Credentials fee of $125.00 (https://www.aczm.org/content.aspx?page_id=587&club_id=366916&actr=3)

First Name

Last Name

Please indicate which subgroup examination you will take

Please indicate which year you will sit for the examination

Home Address

Street Name

City

State/Province

Country

Cell Phone Number

Personal Email Address

Business Address

Business Street Name

Business City

Business State/Province

Business Country

Business Telephone Number

Degrees

DVM/Equivalent

Please enter your school and the year you graduated

Ex) Tufts, 2020

Other Degrees

Please list your other degrees, the school you attended, and the year you graduated

Ex) MBA, Harvard, 2020

License to Practice

States/Provinces/Countries you are licensed to practice in

Ex) License #1: Florida License #2: New York

License Number(s)

Ex) License #1: 123456 License#2: 7891011

Current expiration date of your license

Ex) License #1: 1/20/21 License #2: 2/21/22

ACTION: Please include a scanned copy of your current license

Please check this box stating you are uploading a copy of your license or equivalent. Upload files at the end of this form.

Education & Experience

Documentation of Completion

Please select which route you have completed. Please see below for more information. ACZM Training Program Completed (include documentation with application packet).

If you are currently enrolled in an ACZM-approved training program scheduled to be completed on or before 1 August of the application year, conditional acceptance may occur, and documentation of completion must be provided for final approval of your credentials. Full unconditional approval of credentials is required to sit the examination. Experiential Pathway Completed (include documentation with your application packet that experiential pathway criteria has been met.)

If you are currently in the process of completing 6 years full time zoological medicine experience and will be finished on or before 1 Aug of this year, conditional acceptance may occur, but documentation of completion must be provided by 1 Aug for final approval of your credentials. Full unconditional approval of credentials is required to sit the examination.

Please indicate if you are submitting documentation for a completed residency program or past work experience

ACZM Approved Residency

Experiential Route

ACZM Residency Route

List in chronological order the position(s) of postgraduate training in zoological medicine you have had since veterinary school/college (including dates, location, title of program, and supervisor(s). Indicate major type of experience obtained (clinical, pathology, graduate studies, and species orientation). Include documentation that you completed the training program. Upload files at the end of this form.

ACZM Approved Residency Program 1

ACZM Approved Residency Program 2

Experiential Route

Position 1

Position 2

Position 3

Mentors

All experiential candidates are required to have two Diplomates of the ACZM as mentors by 12 months prior to the examination.

Curriculum Vitae

Curriculum Vitae Requirements

Please check this box stating that you have ensured that your curriculum vitae includes the following information and that you will upload an electronic copy of your curriculum vitae at the end of this form:

-Name

-Address

-Education

-Colleges/Dates/Degrees

-Special training in Zoological Medicine

-Post Graduate Continuing Education

-Scientific and Professional Organizations

-Professional Activities

-Chronologically listed, including job title and supervisor contact information

-Honors

-Professional

-Public Service

-Offices held

-Professional

-Public Service

-Special Contributions to Zoological Medicine

-Bibliography

-Complete list of publications from professional and/or scientific journals, books, proceedings, etc.

-List all refereed (peer-reviewed) publications separately.

Required Publications

Three Required Publications

Please check this box stating that you will enclose an electronic copy of each of the three (3) required publications that you are submitting for the Credentials Committee to review as part of your application. In any articles are currently “in press,” enclose an electronic copy of any letter or letters from journal editor(s) indicating that publications have been fully accepted. Upload files at the end of this form.

Publication 1

Please enter the name of your publication.

Publication 2

Please enter the name of your publication.

Publication 3

Please enter the name of your publication.

Publication (Alternate)

Please enter the name of your publication.

Letters of Reference

Three Letters of Reference

Please check this box stating that you will send the URL below to your three (3) letters of reference from individuals who know you well and are familiar with your experience and knowledge in zoological/wildlife medicine. At least one of these letters must be from an ACZM Diplomate. Letters will be uploaded via this URL: https://app.smartsheet.com/b/form/215d94b2b3b8423ebaf94b8a3ef779f4

Please list the name of the ACZM Diplomate writing your reference letter

*ACZM Diplomate required*

Please list the email address of the ACZM Diplomate writing your reference letter

Please list the name of the second individual writing your reference letter

Please list the email address of the second individual writing your reference letter

Please list the name of the third individual writing your reference letter

Please list the email address of the third individual writing your reference letter

Have you ever been convicted of a felony?

Yes

Have you ever had any legal action taken against any state/province/country issued license?

Yes

Legal Certification

Please type your name as an electronic signature and today's date

I have read the ACZM constitution and By-laws which were provided to me. I agree to disqualification from certification, or to forfeiture and return of such certification, in the event that any of the rules governing such certification are violated by me, or that any of the statements herein made by me are knowingly false, or in the event that I violate or do not comply with any of the provisions concerning certification of the Constitution and By-laws of the College. I agree to hold The American College of Zoological Medicine, its members, examiners, officers and agents free from any damage or complaint by reason of any action they, or any one of them, may take in connection with this application, and/or the failure of said corporation to issue me such certification of qualification or failure to elect me to membership in The American College of Zoological Medicine.

Link to Constitution:

https://drive.google.com/file/d/1JIbIU5iVCLJvZSM5C22lomOb1_YRDI_W/view?usp=sharing

Link to Bylaws:

https://drive.google.com/file/d/1rV91D2kSCcIe_sKAH3sGXHgACq20xTNn/view?usp=sharing

Fees

Please check this box stating that you understand the fee's that accompany this submission.

A credentialing fee of $125 (US) is to accompany the completed application at the time of submission. (If the candidate’s qualifications are deemed inadequate at this time, following evaluation by the ACZM Credentials Committee, the candidate will pay a fee of $125.00 to re-credential.) If payment is submitted and the application is withdrawn prior to the submission deadline, the fee will be refunded minus a $50 (US) processing fee. To pay your application fee, please click this URL: https://www.aczm.org/content.aspx?page_id=587&club_id=366916&actr=3

ACZM Policies on Examination Fee Refunds and Examination Deferment

Please check this box stating that you understand our policy on examination fee refunds and examination deferment

All candidates must take the examination during the year of credentialing.

Within thirty (30) days of being notified of successful credentialing, a candidate must notify the Secretary (secretary@aczm.org), in writing, if they wish to defer taking the examination for hardship reasons. Deferment is defined as allowing the candidate to sit the examination at the next offering of the examination. If a candidate who defers fails to sit at the next opportunity, the examination fee is forfeited.

Hardship is defined as illness in the candidate or major illness or death in the immediate family of the candidate.

Candidates wishing to defer must notify the Secretary in writing. The Secretary will bring the matter to the Executive Committee for anonymous consideration. The Executive Committee will determine if deferment due to hardship is granted. The Secretary will notify the candidate and the Exam Committee Chairperson of the decision.

Maintenance of Certification (MOC)

Please check this box stating that you understand maintenance of certification is required for all ACZM Diplomates.

The American Board of Veterinary Specialties (ABVS) requires all individuals passing board certification requirements in 2016 and beyond to be subject to maintenance of certification no less than once every 10 years.

Application Materials Due Date

Application materials must be submitted electronically, via this form, by March 31, 2026, at 11:59 PM North American Central Daylight Time (UTC-5).

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