Certification Name Change Application

Please fill out the application below. You can submit the form digitally as well as submit your payment via PayPal. There will be a link in the confirmation window after you submit your form that will take you to our PayPal portal. If you prefer to fill out a hard copy of the application and mail a check, the instructions for how to do so are on the bottom of this page.

The name change application fee is $10.00.

Certification Name Change

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Place of Employment(Required)

Work Phone(Required)

Work Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Product Name

Total

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Print the 2021 Certification Application

Printed application Instructions:

Fill out and sign the application
Make check payable to BSVTA:
o New certification Fee: $75
o Renewal Certification Fee: $75 (postmarked before Dec 31 st )
o Late Renewal Certification Fee: $100 (postmarked after Dec 31 st )

Return all documentation to:

BIG SKY VETERINARY TECHNICIAN ASSOCIATION c/o Marcia Cantrell, CVT 6 Stallion Ridge Livingston, MT 59047