Seminar Series Registration Form
Print out this form and mail or fax to DC Academy (703-742-8745)

Registration Status:   New____   Renew/Reinstate____   Date Joined ____

The membership year runs from July 1 to June 30. Please note address changes below.
If there are no changes, please mark NO CHANGES and return.   ________No changes

To be included in our new directory, please fill out form and return with your payment.

Name____________________________ Last Four Digits of Social Security #________________

Maiden Name______________________ Spouse’s Name ______________________

Hospital/Organization Name________________________________________________

Business Address_________________________________________________________

_______________________________________________________________________

Office Phone (       )__________________ Home Phone (       )____________________

Home Address___________________________________________________________

_______________________________________________________________________

E-mail Address/Web Page URL _____________________________________________

Which address do you prefer for academy mailings?  Home ___   Office ___   Other ___

Veterinary School ____________________________________  Year Graduated ______

Checks are made payable to: DCAVM, P.O. Box 710477, Herndon, VA 20171
Your cancelled check is a valid receipt; if additional receipt is required, check here ____

FEES:New Graduate (cash or check only)$195
    Earlybird (cash or check only)$430
    Payments after August 16, 2007$470 (credit cards accepted at on-site registration only)

Please charge my   VISA  ____   MASTERCARD  ____ 3 Digit Security Code _____

Acct# __________________________________________  Exp. Date ______________

Signature ______________________________________________________________

Name on Card (please print) _______________________________________________