Michigan Association of Veterinary Technicians

 

Application for 2012 Individual Membership

 

 

Applicant's Name:

 

Veterinary Technician Student (school):

 

LVT, Year of Graduation:

Institution/school:

 

Michigan VT License #:

 

Other:

 

New Membership

 

Renewal

 

 

Active (LVT) ($30.00)

 

Associate (VT student) ($10.00)

 

 

Affiliate ($25.00)

 

Hospital (1-5 LVT's $30/LVT; >5 LVT's $25/LVT)

 

 

Home Address: 

 

City:

State:

Zip:

 

Business Name/ Address: 

 

City:

State:

Zip:

 

Telephone:

(Primary) 
(Work)   
(Fax)       

 

Email Address: 

 

Preferred place to receive mailings:

Home

 

Business

 

Yes, I would like to receive promotional mailings from veterinary vendors who support the MAVT.

 

Employment Type:

Companion animal practice Research
Large animal practice Teaching
Mixed animal practice Other 

 

If payment is online through PayPal, include full name of person on credit card if other than person filling out membership form:  

 

 

This application valid through December 31, 2012

 

(On the following page you will be redirected to PayPal for on-line payment)

 

If you have already submitted your membership form and need to go back to the PayPal payment page please click the link below.

Member Application PayPal Payment Page