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Delaware Veterinary Medical Association
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2017 Delaware Veterinary Medical Association Dues Form
This is the online dues form for 2017. Please fill out COMPLETELY. The information you provide here will be used to interact with you over the course of the year. Please be serious and accurate as this information will also be published in the Member Directory. Additionally, we are building a new membership database in order to serve you better - please do not assume we know your information - complete records are vital to the success of DVMA moving forward. IMPORTANT: Once you have completed and submitted this form, you will be sent an invoice via email within a few days. Please be sure to be on the lookout for that. This new system will allow you to pay online directly from that emailed invoice or submit it to your hospital for payment by check or credit card. Please call us with any questions you may have 302-455-VETS.
Title (Dr., Ms., Mr., etc)
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LAST Name
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FIRST Name (If you only use an initial - please fill that in here as well)
Your answer
Middle Initial (If you go by your Middle name, please fill that in here)
Your answer
Credentials
Role at Your Practice (Check all that are appropriate)
Required
Gender
Primary Email (Where DVMA info will be sent)
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Primary Phone number
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Mobile Phone Number
Your answer
Primary Mailing Address for DVMA Information (Street)
Your answer
Primary Mailing Address for DVMA Information (City)
Your answer
Primary Mailing Address for DVMA Information (State - Two Initials)
Your answer
Primary Mailing Address for DVMA Information (Zip)
Your answer
Primary Mailing Address for DVMA Information (County)
Your answer
DVMA Original Join Date (Year Only) - please approximate if you aren't sure
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Primary Veterinary School Attended
Your answer
Primary Veterinary School - Year of Graduation
Your answer
Other Schools Attended that you would like DVMA to know about
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I have been/am a beneficiary of the DIVME state funding program
I have been/am a beneficiary of the DVMA Scholarship
Hospital Name (Please enter full name)
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Hospital Address: Street
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Hospital Address: City
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Hospital Address: State
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Hospital Address: Zip
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Hospital Address: County
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Hospital Main Phone Number
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Hospital Practice Type (check as many as are applicable)
Required
Hospital Office Administrator's Name
Your answer
Hospital Office Administrator's Email
Your answer
I would be interested in attending the Veterinary Leadership Conference on behalf of DVMA (must be a veterinarian within 15 years of graduation). This typically takes place in January of each year.
I understand that DVMA communicates primarily through email and other electronic and digital methods. I give my permission to be called, emailed, or texted with information related to Association business. I understand that if I select "no" then I will miss out on valuable and important membership information.
I understand that the DVMA newsletter will no longer be distributed in print. I will look for it via email and/or to be posted on the website.
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