2011-2012 Delaware Valley Academy of Veterinary Medicine
Seminar Series Registration Form

The membership year runs from July 1, 2011 to June 30, 2012..

Series registration is veterinarian-specific and is non-transferable. Series registration permits attendance at all six seminars within the seminar series. Benefits for registering for the entire series include the following:

• Savings of more than $189.00 over the individual seminar fee if registered by August 23, 2010.
• The DV Academy of Veterinary Medicine will archive your continuing education credits and mail you a continuing education statement at the end of the program year.
• Meeting announcements by mail to your designated mailing address.
• Access to seminar handouts via the DV Academy Web site.

Please PRINT when filling out this form. Fill out completely and return with your payment. Only one person per registration form, please.

Name ___________________________ Last Four Digits of Social Security No. ___________

Maiden Name ____________________ Spouses's Name _____________________

Hospital/Organization Name

___________________________________________________________

Business Address

____________________________________________________________________

City ________________________________ State ______ Zip _______________

Office Phone (___) __________________ Home Phone (____) ___________________

Home Address ________________________________________________________

City __________________________________ State ______ Zip ______________


Which Address do you wish to use for Academy mailings: Home ___ Office ___

Email address _____________________________ Web Address ________________________________

Veterinary School _________________________________________________ Year Graduated _________

CHECKS ARE MADE PAYABLE TO DVAVM.
Please mail them to: DVAVM • 1950 Butler Pike, #248 • Conshohocken, PA 19428
Phone 215-284-7050 • Fax: 703-742-8745 • Contact Us

Your cancelled check is a valid receipt; however, if additional receipt is required, check here ___.

FEES:
Recent Graduate (after May 1, 2007)        $150.00
Early Registration Discount                      $349.00 prior to August 23, 2011 (checks only)
All payments after August 23, 2010          $389.00

Please charge my VISA ___ Mastercard ___ Amount $389

Account # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _   Exp Date _ _ / _ _

3-digit Security code on back of card   _ _ _

Signature __________________________________ Printed Name _______________________

The DV Academy is not liable for seminar cancellations due to weather or other causes out of its control.