ONLINE QERA VET APPLICATION FORM

This form is for Vets wishing to work at endurance rides, under the supervision of a Head Veterinarian.

QERA VET APPLICATION FORM

Please complete all fields before submitting this form.
If you have any questions in relation to this form please email the QERA Registrar: [email protected]

VET DETAILS
Full Name:
Preferred Christian Name:
Practice Name:
Address:
Phone Number (Work):
Phone Number (Mobile):
Phone Number (Fax):
Email Address:
Date Of Registration:
Registration Number:
University Of Qualification:
Type Of Practice: SMALL LARGE MIXED EQUINE
Brief History Of Previous Experience:
Would you like to receive a regular QERA newsletter? YES NO
VETERINARIAN DECLARATION:

I hereby agree to abide by all current Australian Endurance Riders Association riding rules, procedures for rides, vetting procedures and Queensland Endurance Riders Association Inc Organisers’ Rules and Procedures and to conduct myself in a manner not to be injurious or prejudicial to the character or interests of the sport of Endurance Riding. In consideration of the State Veterinary Panel accepting this entry, I hereby for myself, heirs, executors, administrators, waive and release the ride organization committee and all persons or organizations associated with the ride, their representatives, heirs, executors, administrators and assign from any rights, claims, or liabilities for damages for injuries sustained by/to me.I hereby authorize QERA Inc and the QERA Veterinary Panel to publish my contact details (shown above) to Ride Committees for the purposes of selecting veterinarians to run their events.

Acceptance of Declaration Decline of Declaration

THANKYOU FOR TAKING THE TIME TO COMPLETE THIS INFORMATION FOR OUR RECORDS
TO BE KEPT UP TO DATE PLEASE JOIN THE OFFICIAL VET CHATLINE [email protected]