2008 Membership Application
Membership fees: checks payable to North Dakota Veterinary Technician Association
_____ $20 before May 1st _____ $25 after May 1st _____ $5 discount for 2008 graduates
Membership Category:
? Active (open to all graduates of
AVMA accredited programs)
? Associate (open
to those interested in supporting and promoting the Association, assistants,
students, and on-the-job trained personnel)
Return application and remittance to: (do not send to PO
Box!)
Karen Schimming, LVT
324 3rd Ave
Enderlin, ND 58027
Completed forms are due January 31st -
*After May 31st
you will not be sent a membership directory
Personal Information please check box if renewal membership ______
Name:________________________________________________________________________________
last first maiden (if applicable)
Address:______________________________________________________________________________
street
city
state zip code
Phone number:_________________________________ E-mail
address:______________________________
How do you want your newsletter sent? _____ US postal mail service _____ E-mail
Employment Information
Place of
employment:____________________________________________________________________
Address:______________________________________________________________________________
street
city
state zip code
Phone number:__________________________ Fax
number:________________________________
Type of
employment:____________________________________________________________________
School and License Information
School attended:_______________________________________ Year of graduation:_____
Licensed yes _____ no _____ If licensed: License number:__________ Issuing state:______
FOR OFFICE USE ONLY
DATE PD.
AMT. PD.
TYPE OF CHECK
CHECK #