TEST PAGE

Membership Category -- Select One

ActiveAssociateStudent1st Year PIMA Student

Full Name

Your Email

Your Phone

Home Address (include state & zip)

Place of Employment

Work Address (include state & zip)

Work Phone

Please select one of the following that best suits your current position:

Small AnimalLarge AnimalMixed PracticeExoticsLaboratory/ResearchOther

Please select ONE of the following membership types:

Renewal MembershipNew Membership

If this is a renewal, has your information changed from last year? Yes or no?

If this is a new membership, please provide the school you attended and your year of graduation:

If this is a new membership, please email a copy of your of your diploma from a 2 year program as well as your VTNE score to marciacantrellcvt64@gmail.com. You will also need to provide a statement from your previous state of residence (if applicable), which indicates that you are in good standing and select from the list of three license options below.

PLEASE NOTE: This form is for BSVTA Membership only. To become Certified in the State of Montana, please fill out a separate application form.