Application
for Re-examination
Date: _____________
Name: ___________________________________________________________
Home
Address: ___________________________________________________
________________________________________________________________
Phone: ______________ Fax:
_______________ E-mail: ___________
Current
Employer:
_______________________________________________
Employment
Address:
_____________________________________________
______________________________________________________________
Current
Supervisor:
_____________________________________________
Supervisor phone: __________________ E-mail: _____________________
Please check the appropriate box to indicate your current
status in the ACVA examination process:
Sitting a 2nd or 3rd time (written
___ , oral exam ___) after initial application
Initiating the 3 year process for a
second time
Sitting the 2nd or 3rd time of a 2nd
3 year cycle
Fees and application requirements:
The re-examination fee for 2nd and 3rd efforts on the written or oral exam within a 3 year cycle is $100 to be sent, with this form to the executive secretary by December 31 of the year prior to the written examination.
The re-application fee for initiating a 2nd 3 year cycle is $500 to be sent, with this form and an updated curriculum vitae to the executive secretary by December 31 of the year prior to examination.
The
ACVA Executive Secretary for the term January 1, 2007 – December 31, 2009 is: