PIMA Student Membership Application

    Membership Category -- Select One

    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.

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