Student Membership
Please complete the form below to apply for Student Membership with the MVMA.
Legal Name
*
First Name
Last Name
Preferred Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Information
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Heading
I am applying for the following type of Student Membership
*
veterinarian
veterinary technologist
Name of CVMA/AVMA accredited program currently attending
*
I authorize the Manitoba Veterinary Medical Association to contact my educational institution to verify my enrolment.
*
Yes
Please upload a copy of one of the following: Official/Unofficial Transcript, Student ID Card, Acceptance Letter
*
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of
Anticipated Month and Year of Graduation
Declarations
I understand that I must notify the Manitoba Veterinary Medical Association should I no longer be enrolled in my current CVMA/AVMA accredited Program.
*
Yes
I confirm that the information contained in this application is accurate.
*
Yes
Signature
Date of Signature
-
Month
-
Day
Year
Date
Submit
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