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WPVMA 2009 Membership Application Form
Applicant Information
First Name*:
Last Name*:
Address:
City:
State:
Zip Code:
Phone:
Email*:
Fax:
College:
Year Graduated*:
Work Information
Work Place:
Address:
How Long?:
City:
State:
Zip Code:
Phone:
Fax:
Position:
Specialty:
Small Animal
General Practice
Cardiology
Surgery
Exotics
Emergency/Critical Care
Other
URL:
Web Account Info
Login*:
Password*:
Dues Information
Full Active Member:
$125.00 per year. The WPVMA is your local subgroup of the PVMA.
Associate Member:
$50.00 per year. You belong to another local subgroup of the PVMA/other state VMA & wish to receive our newsletter & attend an occasional meeting. Please specify your primary local organization.
New Graduate:
$0.00 1st year. First Year Veterinarians who join after June 1st of the year they graduated for the remainder of that calendar year.
Retired:
$0.00 per year. Was active WPVMA member for at least one year & is now permanently retired & maintains no current license. No CE credit will be awarded to these members. These members must still submit a yearly application.
Contact Permissions
I would like my business information listed on the website
I would like to receive email updates
Mailings should go to my home address
