Student Membership Application Form

If you join	Your Dues are	Your Membership will be valid until
July 1, 2008	$28	June 30, 2009
		This is a one year membership only

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):

Education

AVMA Technician School:

Year Will Graduate:

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Colorado Association of Certified Veterinary Technicians

Student Membership Application Form