JOIN NOW OR PAY MEMBERSHIP DUES

Payment (Renewal or New Member) can be made online by filling out the form below. Please complete ALL information, both personal and public, in the form below, as AEMV will use this to create or update your member profile in our database. When you have filled out the form, press the Next Step button to go to the online Verisign payment area.

First Name

Member Type

Last Name

Degrees

Middle I.

Board Specialties

Title

Email Address

If you are a resident/intern/technician, please supply the following additional information:

Employer or Faculty Mentor:

Mentor Phone

Mentor Email

Existing Member?

If you are an existing member making a dues payment, please check this box.

PLEASE NOTE: AEMV does not currently pro-rate dues. We are currently accepting 2010 new memberships and dues payments. If you are a new member, please feel free to submit this application now. Your AEMV membership will be processed in early January, 2010, at which point you will receive a welcome email that contains a temporary username and password to gain access to the Members-Only section of the AEMV website.

Personal Information

Public Information

Personal information is NOT displayed at the AEMV website. It is used for administrative purposes only.

Clinic

Home Address

Address

City

U.S. State

Other Province

Zip Code

Country

Phone

University**

Fax

Year Graduated**

Clinic Website

**If you are a student, you must enter this information.

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