Academy of Internal Medicine for Veterinary Technicians

Prospective Member Form

Name:_____________________________________ Tech Title(s): ______

Home Address: ________________________________________________

City: _________________________________ State:__________________

Zip Code: _______________ Home Phone:__________________________

Employer: ____________________________________________________

Work Address: _______________________________________________

City: ______________________________ State: ___________________

Zip Code: _______________ Work Phone: __________________________

Primary Address (please select):     pHome  pWork

Email Address: _______________________________________________

Area of Interest (select only one):

pSmall Animal Medicine

pLarge Animal Medicine

pCardiology

pOncology

pNeurology