Application for New VIC Member

Application for New VIC Member
Contact Information
First Name*
Last Name*
First Name
Degrees / Credentials*
List relevant degrees (Institution, Degree, Field) and professional certifications. If none, enter N/A.
Email Address*
Current Professional Title/Role*
Current Organization / Employer*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Mobile Number*
LinkedIn Profile URL *
If none, enter N/A.
Upload CV/Resume*

pdf, doc, docx files only
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Headshot

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Executive Experience
Executive Leadership History (Position 1): List Title, Organization and Dates. Summarize experience (Max 150 words).*

0/150
Executive Leadership History (Position 2): List Title, Organization and Dates. Summarize experience (Max 150 words).*

0/150
Executive Leadership History (Position 3): List Title, Organization and Dates. Summarize experience (Max 150 words).*

0/150
Prior Professional Leadership Experience: List organization, your role (e.g., Chair, Member), and dates of service for any prior boards, professional associations, advisory boards, task forces and/or councils.*
In none, enter N/A.
Do you have any conflicts of interest?*

YesNo
If yes, please list your current or upcoming conflicts of interest.

Your Vision
Disruptive Leadership Example: Describe a time you successfully led an organization or major division through a period of significant technological disruption or strategic pivot. (Max 300 words).*

0/300
Top Two Emerging Trends: Identify the top two emerging trends that will impact animal healthcare in the next five years. (Max 300 words).*

0/300
Strategic Positioning: How should VIC strategically position itself to capitalize on one of these trends? (Max 300 words).*

0/300
Animal Healthcare Commitment: What drives your passion for improving animal health and welfare? (Max 300 words).*

0/300
Statement of Interest: Beyond your stated qualifications, articulate your personal motivation in joining the new Council. Specifically, draw upon your unique experience and what you would contribute to ensure continued success? (Max 300 words).*

0/300

Commitment
If selected, I agree to attend quarterly meetings (virtual or in-person, 2-8 hours per meeting).*

YesNo
If selected, I agree to agree to participate in working groups or task forces.*

YesNo
If selected, I agree to provide programmatic expertise (speaker recommendations, lecture topic brainstorming, content and delivery format ideas, etc.) for the Veterinary Innovation Summit.*

YesNo
If selected, I agree to provide engage in professional outreach through events, publications or mentorship as a VIC representative.*

YesNo
By entering my full legal name, I attest that the information provided is true and accurate to the best of my knowledge.*

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Contact Information