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 2016 MID-ATLANTIC STATES VETERINARY CLINIC
Sponsored by the Maryland Veterinary Medical Association

Registration Form

Fill out the form below to register for the clinic. If you prefer to register by fax or mail, click here to download a registration form to print.

Registration Fees

On or Before 5/9/16

After 5/9/16

 

Member Veterinarian

$235

$255

 

Non-member Veterinarian

$285

$300

 

Technician

$185

$205

 

Student (veterinary student ID required at the door)

$155

$155

 

First Registrant

Name Nickname     

Degree (DVM, etc.)                                                                                              $

Member Veterinarian   Non-Member Veterinarian  Technician     Student  


Second Registrant

Name Nickname          

Degree (DVM, etc.)                                                                                              $

Member Veterinarian   Non-Member Veterinarian   Technician     Student      


                                               $


PAYMENT INFORMATION

Practice Name

Address 

City

   State     Zip

Work Phone

  Fax  

E-mail

 Please charge $  to my:

VISA   MasterCard   American Express

Card Number Exp. Date   CSC # What's this?

Cardholder name

Billing Address

City

   State     Zip

IMPORTANT: If you have a disability or dietary need and require special accommodation in order to fully participate in this event, please include a written description below. We can only provide access if we have prior notice.

NO REFUNDS AFTER MAY 9, 2016

       

Sponsored by:

 

 


MVMA Privacy Notice l MVMA Security Policy l MVMA Return Policy

 

2016 Maryland Veterinary Medical Association

Maryland Veterinary Medical Association l PO Box 5407 l Annapolis, MD 21403
phone: 410-268-1311 l fax: 410-268-1322

e-mail: MVMA@KeyAssnMgt.com