Western Australian Consolidated Regulations

VETERINARY SURGEONS REGULATIONS 1979 - SCHEDULE 1

[r. 34, 35, 37, 38]

        [Heading inserted in Gazette 20 Mar 2007 p. 1030.]

1.         Application to register veterinary clinic or hospital

Application to register veterinary clinic or hospital		Veterinary Surgeons Act 1960 s. 24A
Applicant (person who will be managing veterinary surgeon)	Name ______________________________________________ Address ________________________________________ _______________________________________________ Telephone _______________         Fax __________________ Email
Premises	❑ Veterinary clinic         ❑ Veterinary hospital
	Name of clinic/hospital
	Street address ________________________________________ _______________________________________________ Postal address         __________________________________ _______________________________________________ Telephone _______________         Fax __________________ Email
	Owner or lessee of premises Name __________________________________________ Address ________________________________________
Signature	________________________________ __________________ Applicant Date

        [Form 1 inserted in Gazette 20 Mar 2007 p. 1030.]

2.         Certificate of registration of a veterinary clinic or hospital

Veterinary Surgeons Act 1960 Certificate of registration of veterinary clinic*

This is to certify that the [name] _______________________________________________________________ at [address] ______________________________________________________________ managed by _________________________________________________ is registered as veterinary clinic* under the Veterinary Surgeons Act 1960 . The registration is valid for 3 years. ___________________________________         ____________________ Registrar of the Veterinary Surgeons’ Board         Date

[* For a veterinary hospital, change “clinic” to “hospital”.]

        [Form 2 inserted in Gazette 20 Mar 2007 p. 1031.]

3.         Application to renew registration of veterinary clinic or hospital

Application to renew registration of veterinary clinic or hospital		Veterinary Surgeons Act 1960 s. 24A
Managing veterinary surgeon	Name ______________________________________________ Address ________________________________________ _______________________________________________ Telephone _______________         Fax __________________ Email
Premises	❑ Veterinary clinic         ❑ Veterinary hospital
	Registration No.
	Name of clinic/hospital
	Street address _________________________________________ _______________________________________________ Postal address         __________________________________ _______________________________________________ Telephone ______________         Fax __________________ Email
	Owner or lessee of premises Name __________________________________________ Address ________________________________________
Signature	_____________________________ _____________________ Managing veterinary surgeon Date

        [Form 3 inserted in Gazette 20 Mar 2007 p. 1031.]

4.         Application to transfer management of veterinary clinic or hospital

Application to transfer management of veterinary clinic or hospital		Veterinary Surgeons Act 1960 s. 24A
Premises	❑ Veterinary clinic         ❑ Veterinary hospital
	Registration No.
	Name of clinic/hospital
	Street address _________________________________________ _______________________________________________ Postal address         __________________________________ _______________________________________________ Telephone ______________         Fax __________________ Email
Managing veterinary surgeon	Current managing veterinary surgeon Name __________________________________________ New managing veterinary surgeon Name __________________________________________ Address ________________________________________ _______________________________________________ Telephone ______________         Fax __________________ Email
Signature	________________________________ ________________ Current managing veterinary surgeon Date _____________________________ ______________ New managing veterinary surgeon Date

        [Form 4 inserted in Gazette 20 Mar 2007 p. 1032.]