Membership form

Submit or edit your contact information here.  Please complete all information fields. Please note that you must be a veterinarian to qualify for membership.  If you need to pay your dues, the information that you will need is on the Membership Dues page.

* Required fields
Name *
E-mail Address *
Do you want to become a member? Yes
No
Are you a new or renewing member? New
Renewing
Is this a change in your contact information? Yes
No
Business name
Business address (number, street name and suite)
Business city, state and zip code
Business phone (area code and number)
Fax Number
Cell phone (area code and number)
Home address (number, street, apartment number)
Home city, state and zip code
Home phone (area code and number)
For correspondence, I prefer to use my Business address
Home address
Veterinary School and Graduation Year

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Please note that we do share member contact information with Affiliated Veterinary Specialists' Grand Rounds so that you can receive their email invitations.  If there is any information that you do not want us to post on our membership list (which is password protected), then please notify Dr. Cindy Miller (drcindyinjax@yahoo.com).