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	$195 without printed notes / $240 with printed notes
Earlybird: Before 8/16/10 (no credit card accepted)	$445 without printed notes / $490 with printed notes
Standard: After 8/16/10	$485 without printed notes / $530 with printed notes
Single Seminar Fee:	$145

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

Amount (circle one)   $485.00    $530.00

Acct# __________________________________________  Exp. Date ______________

Signature ______________________________________________________________