Membership fees: checks payable to North Dakota Veterinary Technician Association

 _____  $20 before Jan 31st      _____  $25 after Jan 31st              _____   $5 discount for 2010 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!)
Kim Krzyzaniak, LVT
2530 14 St S #206
Fargo, ND  58103

Completed forms are due January 31st

Personal Information please check if renewing membership ______

Name:________________________________________________________________________________
last first maiden  (if applicable)
Address:______________________________________________________________________________
               street                                  city                                                        state           zip code
Phone number:_________________________ E-mail address:____________________________________

Place of employment:____________________________________________________________________


               street                                 city                                                           state           zip code
Phone number:__________________________ Fax number:________________________________

Type of employment:____________________________________________________________________

School attended:_______________________________________ Year of graduation:_____

Licensed   yes _____         no _____           If licensed: License number:__________ Issuing state:______

FOR OFFICE USE ONLY

DATE PD._______  AMT. PD.  _________ CHECK # __________