Membership Form

IAVRPT International Association of Veterinary Rehabilitation and Physical Therapy
Application for Membership

Please use this form to apply for or renew your membership on-line.
If you prefer to use regular mail, print out this pdf application form.

Note: required entries are marked with an asterisk.

First Name*:	Middle Initial:
Last Name*:	Suffix:
	Dr. Mr. Ms. Mrs. Other:
	Male Female
Address for Directory of Members: (all correspondence will be directed to this address)
Primary Postal Address*:
Suite or Room or Apt:
City*:
State or Province:
Postal Code*:
Country*:
Web Address:
Telephone*:
Email*:

Academic or Professional Degrees:
Present Affiliation:
Clinic:
University:
Private Business:
Discipline:
Specialty:

	I wish to keep my data confidential and only used by the IAVRPT. I do not want my details included in the “Directory of Members”

Membership Type*:
	Active Member $50 (vet, PT,VT with pertinent university degree) Associate Member $30 (other professional with interest in rehab)
	I am renewing my membership in IAVRPT.

Payment Type*: (to be made after form submission)
	PayPal Credit Card (Mastercard, Visa, American Express, Discover) Personal Check

	I accept the proxy requirement of the IAVRPT Bylaws.

Questions?

Contact:
Darryl Millis, IAVRPT Treasurer
Email: boneplate@aol.com
Fax: 865-974-5554
Mail: IAVRPT
c/o Dr. Darryl Millis, Treasurer
8309 Birch Run Lane
Knoxville, TN 37919

IAVRPT International Association of Veterinary Rehabilitation and Physical Therapy Application for Membership

IAVRPT International Association of Veterinary Rehabilitation and Physical Therapy
Application for Membership