Membership Information
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| Last Name
First Name
Title: Dr, Mr, Ms
Diplomate Certification
|
|
Mailing Address
Where you would like to receive
newsletters, conference notices, etc.
CityState
Zip Code + 4
Country
|
|
| Email Address
Home Phone
Work Phone
Fax
|
Please enter numbers only without spaces or punctuation. Never published but used only if a problem develops with your registration.
Please enter numbers only without
spaces or punctuation.
Please enter
numbers only without spaces or punctuation.
|
Veterinary Affiliation Information
Under Affiliation Name and subsequent questions,
list whatever company you work for: veterinary practice, college,
company, your own name, etc.
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| Affiliation Name
Affiliation Town
Affiliation State
Affiliation Zip Code
Affiliation Website
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Enter Zip + 4 for US addresses.
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MASAAV publishes a member veterinarians
list on the Internet;
veterinarians are listed unless
otherwise requested.
Only veterinarian's name, practice name,
practice city, state, zip code and website plus work phone are listed in this
directory.
Do
not include me in the MASAAV directory online.
|
Membership Category
Click on the drop down list arrow and choose the appropriate
category.
|
Select
Veterinarian, Resident, Intern -
$50
Associate (Technician/Nurse) -
$50
Veterinary Student, Technician Student -
$25
Pamela Slack Award Winner - Free
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|
Amount Due --->
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$
Enter the amount of money due.
|
| Comments:
|
- - - Chose Payment Method - - -
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The most secure and convenient payment method is PayPal
located at the bottom of this page. |
If paying MASAAV directly by credit card, fill out Credit Card Information
below..
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Credit Card Information
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|
Type of Credit Card
|
|
| Card Number: |
Numbers only, no dashes or spaces.
|
| Exp Date: |
mm/yy Must be 2
numbers / 2 numbers.
|
| Credit Card Verification Code |
Must be 3 numbers found on back of card,
or 4 numbers on front for AmEx. |
| Name on card: |
Name on the card.
|
| Card billing street address: |
Street address for card bill.
City and state not required unless outside of the US. |
| Card billing Zip
Code: |
Zip code for card bill.
|
