PO Box 11648 Durham, NC 27703        888-NCAVTEC          www.ncavt.com

Membership Application
                  
New____   Renewal_____   Mailing List______  Date of Application____________

Name___________________________________________________________
Address_________________________________________________________
City____________________________________________________________
State___________________________________________________________
Zip Code________________________________________________________
Phone: Home (   )_______________________________
           Work  (   )_______________________________
E-mail address____________________________@_____________________

Unless otherwise requested, beginning in April, all newsletters will be sent via e-mail instead of regular mail.  Therefore, when renewing your membership, please make sure we have your current e-mail address on file.  Of course, if we have no e-mail address on file, your newsletter will still arrive through the US Postal Service.  Thank you!

If employed, please complete:

Employer_______________________________________________________
Address________________________________________________________
City___________________________________________________________
State__________________________________________________________
Zip Code__________________________
Type of business_________________________________________________

School of Graduation:____________________________________________
Date of Graduation:_______________________
NC Registration number:___________________

Type of membership:
*Active ($30.00)_____ **Associate ($35.00)_____
***Student ($20.00)____  Mailing list ($15.00)_____
If student, school__________________________
Expected Date of Graduation________________


Signature_________________________________

Please enclose check/money order made payable to: NCAVT
Return to:   Membership
                  PO Box 11648
                  Durham, NC   27703

*Active: Veterinary Technician Registered in North Carolina
**Associate: Graduate of an accredited program of Veterinary Technology, but not registered in   North Carolina
***Student:  Student in an accredited program of Veterinary Medical Technology who is within 12 months of graduation