Auto Renew Veterinarian Membership

Current Employer or Academic Institution Name *

Business/Institution Address *Please provide the street address of your employer or academic institution

Business/Institution Address 2 (optional)Suite number, etc.

Business/Institution City *

Business/Institution State (or Province if outside of the US) *

Business/Institution ZIP or Postal Code *

Business/Institution Country *

Business/Institution Phone *

Business/Institution Email *What is the main business email for this company or institution? (Students can use "N/A")

AVMA Accredited College? * Yes No Currently attending or has graduated from an AVMA accredited college of veterinary medicine?

Graduation Date *Graduation date from college of veterinary medicine, technology or nursing (Students indicate your expected graduation date)

Located In North America? * Yes No Are you currently attending or graduated from a North American school of veterinary technology or veterinary nursing?

AAFV Sponsor Name and Email *For Student Associate members, please provide your AAFV sponsor and email (other members, use N/A). If you do not have a mentor, please contact Dr. Stilwell at jstilwell19@gmail.com

Title/Degree/Certification *Students: if not applicable yet please use "N/A"

Phone Number (home/cell) *

Active State Licenses *List active state licenses for veterinarians and license or equivalent for paraprofessionals (if not applicable then use N/A)