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	Illinois Veterinary Medical Foundation

The ISVMA would like to thank our Platinum Sponsors who have generously supported ISVMA programs and services for the benefit of our members:

Membership Application/Renewal Form

Fill out and send us the following form and we'll invoice you for your dues...become part of your state professional association!

Tell us what you think about our web site, our services, our organization, or anything else that comes to mind. We welcome all of your comments and suggestions.

New Membership OR Renewal of Current Membership

*Join now by pre-paying your 2008-2009 membership dues and you will receive the remainder of the 2007-2008 membership year for free!
Your membership investment will not expire until June 30, 2009.

Membership Type:

Veterinary Medicine Political Action Committee

Illinois Veterinary Medical Foundation Contribution

Applicant Name:

Name of Sponsoring Veterinarian :

Spouse/Partner Name:

Illinois Veterinary License #:

Business Name:

Business Phone:

Business Fax:

E-mail Address:

Business Address:

Home Address:

Home Phone:

Mailing Preference: Business Home

Birth Date:

Gender:

Degree(s):

Veterinary College of Graduation: Year:

Present Working Status:

Type of Practice:

Setting of Professional Activity:

Primary Employment:

Employed By:

Primary Specialty:

Please contact me as soon as possible regarding this application.

Illinois State Veterinary Medical Association
1121 Chatham Road
Springfield, IL 62704

Phone: (217) 546-8381

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