NEW MEMBER APPLICATION

ASSOCIATION FOR VETERINARY EPIDEMIOLOGY AND PREVENTIVE MEDICINE

Print out, complete, and return the form below and dues (US $20.00 ) to:

Dr. James Thorne, Secretary/Treasurer, AVEPM 3310 Cheavens Rd Columbia, MO 65201-9383	Pay online through
	E-mail AVEPM at AVEPM@centurytel.net

NEW APPLICATION ___   RENEWAL ___   CHECK ENCLOSED ___   PAID ONLINE ___

DATE: _____/____/____

NAME: _____________________________________________________
              First         M.I.            Last

E-mail address (newsletter will be sent here as pdf file):

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Mailing address:

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          City                  State      Zip Code

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              Country

Business Phone: (_____)___________________

FAX: (_____)______________________________

E-Mail: __________________________________

Degrees: __________________________________________________

Board Certification: ______________________________________

Present Position: _________________________________________

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Major area of current activity in veterinary public
health and preventive medicine:

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Membership dues are payable to AVEPM on January 1 of each year.
The AVEPM Constitution and By-Laws require that members two years
in arrears in payment of dues shall be dropped from membership (Article VI)