Application form - 2019 MAVT Individual Membership
This application valid through December 31, 2019
First Name *
Your answer
Last Name *
Your answer
Type: *
E-mail Address *
This is where you will receive your quarterly e-newsletter.
Your answer
Verify Email Address *
Your answer
Telephone (Primary) *
Your answer
Home Address: *
Your answer
Home City: *
Your answer
Home State: *
Your answer
Home Zip Code: *
Your answer
Employer/Business Name:
Your answer
Business Address:
Your answer
Business City:
Your answer
Business State:
Your answer
Business Zip Code:
Your answer
Business Phone:
Your answer
Employment Type
Membership Information
Membership Status: *
Membership Type: *
LVT Year of Graduation:
(if applicable)
Your answer
LVT or Student Institution or School:
(if applicable)
Your answer
LVT License Number
Number on your license beginning with 690200-
Your answer
Payment Information
Online payment link provided after form submission.
Full Name of Payment Payee:
If payment is online through SquareUp, include full name of person on credit card if other than person filling out membership form.
Your answer
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