WPVMA Membership Application Form

Applicant Information

First Name*:
Last Name*:
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: URL:

Web Account Info

Login*: Password*:    

Dues Information

Full Active Member: $50.00 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. Newly graduated vets who join after June 1 of the year of their graduation with membership extending 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

Mailings should go to my home address