(Current) Membership Application Checks payable to North Dakota Veterinary Technician AssociationMembership Category:(Required) Active (open to all graduates of AVMA accredited veterinary technology programs) Associate (open to those interested in supporting and promoting the Association; veterinarians, assistants, students, and on-the-job trained personnel) Renewal membership New membership To join a committee check here & indicate which committee here here & indicate which committee hereReturn application and remittance to: Diana Johnson 118 E Highland Acres Watford City, ND 58854 Completed forms are due April 1st- Membership applications will not be accepted after July 1st Personal Information(will be for executive board members only) Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone number:(Required)E-mail address:(Required) Employment Information(for executive board members only)Place of employment:Address Street Address City State / Province / Region ZIP / Postal Code Phone number:Fax number:Type of employment/title: For Veterinary Technicians: School and License Information(executive board members only) School attended:(Required)Year of graduation:(Required)Licensed:(Required) Yes No License number:Issuing state:Are you licensed in ND: (according to NDBVME)(Required) Yes No FOR OFFICE USE ONLYDATE PD. MM slash DD slash YYYY AMT. PD.TYPE OF CHECKCHECK #Signature
