Active Association Membership Application Form

FOR NEW APPLICANTS

If you took the VTNE in	Your Dues are	Your CE Requirements are	Your Membership/Certification will be valid until
June 2008	$120	16 hours	June 30, 2010
January 2009	$60	8 hours	June 30, 2010
June 2009	$60	8 hours	June 30, 2010
January 2010	$30	4 hours	June 30, 2010

Attention: people passing the VTNE on June 20, 2008 OR January 16, 2009, please click here for more information.

FOR RENEWING AND TRANSFERRING APPLICANTS

*If you are joining or renewing*	*Your Dues are*	*Your CE Requirements are*	*Your Membership/Certification will be valid until*
on or after July 1, 2008	$120	16 hours	June 30, 2010
on or after July 1, 2009	$60	8 hours	June 30, 2010
If you are transferring in after January 2010	$30	4 hours	June 30, 2010

First Name: *

Middle Initial:

Last Name: *

Former Last Name (if applicable):

Contact Information

Mailing Address: *

City: *

State: *

Zipcode: *

Home Phone:

Work Phone:

Cell Phone:

Email:

By providing an email address, you authorize CACVT to email information such as “Enformation” which is the most up-to-date events. CACVT will never give out email addresses to any other entity. You may opt out at any time.

Preferred Contact Method: *

Other Information

Gender: *

Male

Female

Clinic/Employment (optional):

Preferred Newsletter Version: *

Postal Mail

You may change your method of newsletter delivery at any time.

Education & Certification

AVMA Technician School:

Year Graduated: *

State in which VTNE was taken:

Year Tested:

Colorado certification number (if known; if a new member, a number will be provided):

NAVTA number (if current NAVTA member):

VTS:

Current NAVTA members or VTS receive a discount on membership (fields must be filled in).

If transferring from another state, on what date did you request your scores be sent to Colorado?

Month/Day/Year

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Colorado Association of Certified Veterinary Technicians

Active Association Membership Application Form