Application for ABVM Certification
Applicant Info
First Name:
Middle Initial *optional:
Last Name/Surname:
Date of Birth: / /
Degree:
Specialty:

Contact Info
Address Location: Home    Business
Mailing Address (Line 1):
Mailing Address (Line 2) *optional:
City:
State:
ZIP Code:
Country:
Business Telephone:
Business Fax *optional:
Home Telephone:
Personal Email:
(This is necessary so we can contact you when your certification expires.)




Standard Required Documents
These documents are required to register for either exam.
Curriculum Vitae:
State Medical License:
Primary Board Certification:

Required General Exam Documents
Attach this document only if you are taking the General exam
General Letter of Attestation
or Fellowship Certificate:

(for physicians who have completed
a 12 month fellowship in VM)
View Sample Letter of Attestation

Required Endovascular Exam Documents
Attach these documents only if you are taking the Endovascular exam
Endovascular Letter of Attestation:
View Required Letter of Attestation

Examination Fees
Application Fee: $250.00 (non-refundable)
Examination: $850.00 - General Examination
$1250.00 - Endovascular Exam
$1750.00 - Both Exams (discounted price)
Total Fees:
$250.00

Electronic Signature and Confirmation
By entering your intials and today's date in the box below, you attest that all information entered as well as
any documents supplied are truthful and correct. Your initials and today's date serve as an electronic signature
indicating that you fully understand all terms and guarantee that all information is truthful and correct.
In addition, your IP address will be recorded along with your electronic signature.
Initials & Date:
IP Address: 54.167.15.6

Credit Card Information
Names and addresses of applicants must exactly match information your credit card company has on file,
otherwise your application will not go through. 
Name Printed on Card:
Card Type:
Card Number:
Expiration Date: /
CCV Code:
*The CCV code appears on the reverse side of your card as the last three printed digits on the signature stripe
CCV Location

Final Confirmation
The application fee of $250.00 is not refundable. A $75 Reprocessing fee will be assessed on incomplete applications.
Examination fees are refundable only if the cancellation request is received in writing at least thirty (30) days
in advance of the atart of the exam. No refund of examination fees can be made in the event of later cancellation.
**IMPORTANT: ONLY CLICK THE BUTTON ONCE OR YOU WILL BE CHARGED TWICE.