District
of Columbia Veterinary Medical Association
|
District
of Columbia Veterinary Medical Association
|
| APPLICATION
FOR MEMBERSHIP |
| Date ___________________ |
| I hereby make application for membership in the District of Columbia Veterinary Medical Association: |
| Name |
| ________________________________________________________________________________ |
| (Last) (First) (M.I.) |
| Home Address |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| Mailing Address |
| ________________________________________________________________________________ |
| ________________________________________________________________________________ |
| Telephone Number (Home) __________________ (Office) _____________________ |
| Email: ______________________________ |
| Education: |
School ________________________________________ |
Degree ________ Year _______ |
School ________________________________________ |
Degree ________ Year _______ |
| Professional Activity (Indicate job title and name of agency or employer) |
Job Title ______________________________________________________________ |
Military ______________________________________________________________ |
Practice ______________________________________________________________ |
Public Health ______________________________________________________________ |
Regulatory ______________________________________________________________ |
Other ______________________________________________________________ |
| Signature of two (2) recommending members: |
1. ____________________________________________________ |
Date ___________ |
2. ____________________________________________________ |
Date ___________ |
| Membership Dues: $35.00 |
| ____________________________________________ |
| Make checks
payable to "District of Columbia Veterinary Medical Association" Mail completed application and payment to: |
|
|