2007 HCVMA Membership Renewal Application

Last Name	First Name		Middle Initial
Practice Name
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		Spouses Name
School and Year of Graduation	Degree(s)		Specialty(s)
Professional Activity Code	Employer Type

	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

In an effort to better serve our membership, additional information is being solicited this year for our database. As always, this information is kept confidential. In the event of an emergency, this information will enable us to better serve our profession.

Make checks payable to HCVMA and remit to Dr. Bill Haglund at 9321 Katy Freeway, Houston, Texas 77024

Full Year's Dues $150.00 Due 01/01/2007, Delinquent 04/01/2007. After 04/01/07, dues are $175.