NYCAVMA Membership Enrollment Form
Dues are $50 annually, and membership is for a term of one year.
Member Name
*
First Name
Last Name
Practice Name
If applicable.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Website
If applicable.
Modalties you're certified in - check all that apply.
Acupuncture
Chiropractic
Herbal Medicine: Chinese
Herbal Medicine: Western
Osteopathy
Reiki
Homeopathy
Homotoxicology
Shamanistic Healing
Nutritional
Other
Modalities -Certifications/Degrees
Species Treated
Dogs
Cats
Horses
Farm Animals (Cows, Goats, Llamas, Sheep, Pigs)
Birds/Poultry
Small Animals (Hamsters, Rabbits, Ferrets)
Reptiles
Other
Years of experience
*
Office Hours
If applicable.
Other Info
(Information about your practice/specialties you'd like displayed on the website.)
Payment Method
*
Please send me a PayPal invoice.
I will mail in a check.
Submit
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