Certification Only Application Form

*If you are joining or renewing*	*Your Dues are*	*Your CE Requirements are*	*Your Certification will be valid until*
before July 1, 2007	$130	16 hours	June 30, 2008
on or after July 1, 2007	$65	8 hours	June 30, 2008
July 1, 2008	$147	16 hours	June 30, 2010

This category has NO CACVT membership benefits. It is for people who only want to be certified in the state of Colorado but do not wish to join the Association.

If you wish to join the Association (Active Association Membership Category), certification is included in this membership. Please hit your "back button" and select the Active Association Membership Category (this is the most chosen category for the majority of our members).

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: *

Posted 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

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Colorado Association of Certified Veterinary Technicians

Certification Only Application Form