WVMA Membership

Member Phone Number *

Member Mailing Address: Street *

Member Mailing Address: Line 2 (optional)

Member Address: City *

Member Address: State *

Member Address: ZIP code *

Member Credentials (select all that apply) * DVM MS PhD VMD DABVP DABVT DACAW DACLAM DACPV DACT DACVAA DACVB DACVCP DACVD DACVM DACVO DACVP DACVPM DACVR DACVSMR DACVS DACZM DACVECC DAVCD CVT LVT RVT CVPM Not Applicable

Member Birthdate *mm/dd/yyyy

License Number (or enter non applicable) *

Area of focus (pick one that best describes you) * Companion Animal Equine Food Animal Mixed Animal Board-Certified Specialist Other N/A

Patients Seen (select all that apply) * Non Applicable Aquaculture Avian Bees Canine Dairy/Beef Equine Exotic Companion Animal Feline Reptile and Amphibian Shelter Medicine Small Ruminants Swine Wildlife Zoo/Non-domesticated

Clinic Name (or company, relief, retired etc.) *

County *

Paperless Newsletter in 2024 (Check to receive the monthly newsletter by email only) (optional)