Annual Membership – Licensed Technician

First Name *

MI *

Last Name *

Email *

Clinic Name *

Clinic - Address *

Clinic - City, ST. ZIP *

Work Phone *

Cell Phone *

Residence - Address *

Residence - CITY, ST. ZIP *

Residence Phone *

Would you like mail to be sent to your clinic or home address? * Clinic Address Home Address

To what professional associations do you belong? (AVMA,TVMA, etc.): *

ENDORSED BY CURRENT MEMBER (New Applicants Only) *

Veterinary School Attended (optional)

Spouse's First Name (optional)

Your time in practice is involved with (optional) Primarily Small Animal/Exotics (Over 90 %) Primarily Large Animal (Over 90 %) Mixed Small Animal/ Large Animal (75 % / 25 %) Mixed Small Animal/ Large Animal (25 % / 75 %) Mixed Small Animal/ Large Animal (50 % / 50 %)

Other (optional)

Specialty (optional)