HCVMA Membership Application

Last Name			First Name			Middle Initial
Practice Name						Position
Business Street Address					q Check if Preferred Mailing Address
City			State			Zip
Business Telephone			Business Fax			Business Email Address q Check if Preferred
( )			( )			@
Business Website Address
http://
Home Street Address			q Check if Preferred Mailing Address			How would you like to receive your newsletter?
						q Email q Hardcopy q Both
City			State			Zip
Home Telephone			Home Fax			Home Email Address q Check if Preferred
( )			( )			@
Nickname			Birthdate			Birthplace
School and Year of Graduation			Degree(s)			Specialty(s)
Professional Activity Code			Employer Type			Spouses Name
Previous Practice Locations:						Board Certification:
Do you agree to abide by all the rules and resolutions adopted by a majority of this organization in the past, present and future?
Applicant’s Signature:						Texas License Number:
Recommended for Membership in the HCVMA by (Two HCVMA Member signatures required):
Member Signature:					Member Signature:
Member Name Printed:					Member Name Printed:
	Professional Activity Codes						80	Pathology, Avian
10	Bovine Practice (exclusive)	86		Anesthesiology			81	Pathology, Clinical
11	Equine Practice (exclusive)	87		Internal Medicine			42	Wildlife, Zoo & Fur Bearing Animals
12	Porcine Practice (exclusive)	88		Cardiology			43	Extension
13	Large Animal Practice (all species)	89		Dermatology			44	Diagnostic Veterinary Medicine
14	Mixed Practice (predominantly large)	90		Neurology			45	Industrial Veterinary Medicine
15	Mixed Practice (50-50 Large & Small)	91		Epidemiology			50	Military Veterinary Service
16	Mixed Animal Practice (predominantly Small Animal)	92		Oncology			55	Veterinary Technician Educator
17	Small Animal Practice (exclusive)	93		Aquatic Animal Medicine			60	Other Veterinary Medicine
18	Poultry Practice (exclusive)	94		Avian Medicine			70	Retired
19	Feline Practice (exclusive)	95		Ethology			99	Unknown
20	Anatomy	30		Veterinary Public Health
21	Biochemistry	31		Veterinary Preventative Medicine
22	Microbiology	32		Teaching & Research				Employer Type
23	Parasitology	36		Regulatory Veterinary Medicine			01	College or University
24	Pathology	38		Administration			02	Federal or Dominion Government
25	Pharmacology	41		Laboratory Animal Medicine			04	State or Local Government
26	Physiology	82		Ophthalmology			06	Self-Employed Practice – Owner or Shareholder
27	Radiology	83		Nutrition			07	Private Practice Employee
28	Toxicology	84		Clinician			08	Retired
29	Surgery	85		Theriogenology			30	Other

This information is kept confidential. In the event of an emergency, this information will enable us to better serve our profession.

Mail check for $150.00, payable to HCVMA, and completed application to:

Dr. Seth Landry 8785 Gaylord Dr. Houston, TX 77024 Below to be filled out by HCVMA Secretary:

Passed by Executive Board (Date)

Passed by TSBVME (Date)

Dues Paid Amount and Date (Free membership for new graduates 1^st year only)