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Membership
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2017-2018 Delaware Valley Academy of Veterinary Medicine
Seminar Series Registration Form

The membership year runs from July 1, 2017 to June 30, 2018.

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Please PRINT when filling out this form. Fill out completely and return with your payment. Only one person per registration form, please.


Name ___________________________ Last Four Digits of Social Security No. ___________

Maiden Name ____________________ Spouses's Name _____________________

Hospital/Organization Name ______________________________________________________

Business Address __________________________________________________

City ________________________________ State ______ Zip _______________

Office Phone (___) __________________ Home Phone (____) ___________________

Home Address ________________________________________________________

City __________________________________ State ______ Zip ______________


Which Address do you wish to use for Academy mailings: Home ___ Office ___

Email address _____________________________ Web Address ________________________________

Veterinary School _________________________________________________ Year Graduated _________

CHECKS ARE MADE PAYABLE TO DVAVM.
Please mail them to: DVAVM PO BOX 710477 Herndon, VA 20171
Phone 703-733-0556 Fax: 703-742-8745 Contact Us

Your cancelled check is a valid receipt; however, if additional receipt is required, check here ___.

FEES:
Recent Graduate
(after January 1, 2012)
$160.00
Early Registration Discount $399.00
prior to August 23, 2017 (checks only)
All payments after August 23, 2017 $439.00
Technician – Early Registration: $145
prior to August 23, 2017 (checks only)
Technician -- after August 23, 2017 $175

Please charge my VISA ___ Mastercard ___ Amount $439
Please charge my VISA ___ Mastercard ___ Amount $175 (technician)
Please charge my VISA ___ Mastercard ___ Amount $160 (recent grad)

Account # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _   Exp Date _ _ / _ _

3-digit Security code on back of card   _ _ _

Signature __________________________________ Printed Name _______________________

The Delaware Valley Academy is not liable for seminar cancellations due to weather or other causes out of its control.

 

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