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2012 MVMA Ski Seminar

16 Hours Continuing Education

Registration Form

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

 

REGISTRATION FEES

Before 10/21

 

Veterinarians
 

$675

 

Non veterinarians
(spouse, technician, guest, student, children over 12)

$100

First Registrant

Name Nickname           $

VMD   DVM   RVT  Technician    Spouse  Guest  Student


Second Registrant

Name Nickname           $

VMD   DVM   RVT  Technician    Spouse   Guest Student


Third Registrant

Name Nickname           $

VMD   DVM   RVT  Technician    Spouse   Guest  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 No.  (What's this?)

Cardholder name

Billing Address    Billing 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 FEBRUARY 24, 2012

       

 

 


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2011 Maryland Veterinary Medical Association

Maryland Veterinary Medical Association l 3230 Maiden Lane l Suite 5 l Annapolis, MD 21403
phone: 410-268-1311 l fax: 410-268-1322

e-mail: MVMA@KeyAssnMgt.com