Texas Equine Veterinary Association

www.texasequineva.com • Page 23 VETERINARIAN MEMBERSHIP APPLICATION Name:______________________________________________________________________________________________________ I am renewing my membership. All of my contact information is the same as what is already on file. Clinic, University or Company Name:_____________________________________________________________________________ Equine Speciality:_____________________________________________________________________________________________ Address:______________________________________________________________________________________________________ City:__________________________________________________State:____________Zip:__________________________________ Phone:_______________________________Fax:_______________________________Mobile:_______________________________ Email:________________________________________________Website:________________________________________________ License #:_________________Date of Birth:_________Veterinary School:________________________Graduation Year:__________ Are you interested in serving on a Committee? Yes / Not at this time Are you interested in presenting a Texas Take? Yes / No MEMBERSHIP BENEFITS: • Opportunities for professional development close to home and to build relationships with regional colleagues who share commonalities. • Reduced rates on all TEVA seminars and other meeting fees • Subscription to TEVA's publication e Remuda, a veterinary journal and informational magazine • Link to legislative actions in Austin, which may affect the horse, you, and your practice • Notice of health updates and other news via email • Notice of special rates and discounts from industry businesses and more! LEVELS OF MEMBERSHIP: All memberships are on an annual basis and expire on December 31 of each year. First Person - Regular Annual Membership: $295__________ Second and ird Person - Regular Annual Membership: _______ x $275__________ Annual Intern or Resident Membership: $100__________ Annual Veterinary Student Membership (Includes First Two Years Aer Graduation): $25___________ Annual Retired Veterinarian Membership: $50___________ Annual Veterinarian >65 Years of Age Membership: $150__________ Lifetime Membership: $2500_________ Annual Group Practice Membership: 4+ Veterinarians $1,000_________ (Allows all members of a practice to attend meetings at member rates. TOTAL: $______________ You must include a listing of your entire professional staff on this registration form or an attached sheet, for them to be eligible for this membership. You must enroll 4 or more veterinarians to be eligible for the Group Practice Membership.) PAYMENT: Checks made payable to: Texas Equine Veterinary Association I would like to automatically renew my membership every year, using this credit card information. (An email will be sent to you prior to your card being charged.) CREDIT CARD PAYMENTS ARE ACCEPTED WITH THE FOLLOWING INFORMATION: CREDIT CARD TYPE________#:____________________________________________________EXP DATE:___________________ NAME ON CARD:__________________________________________________________BILLING ZIP CODE:_________________ You may pay online at www.texasequineva.com. Applications may be mailed with credit card information or check. Questions? Please call (806) 673-1987 or email: office.teva@gmail.com | 1015 NW Ave #212 | El Dorado, AR | 71730 2017

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