HARRIS COUNTY VETERINARY MEDICAL ASSOCIATION
Step I: General
Step II: Professional
Step III: Practice
Step IV: Finish
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General / Contact Information
Title
DR
Please check if you are 65 years old and have been a HCVMA member for 20 consecutive years
First Name
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Last Name
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Email Address
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Home Address
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City
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State
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Zip
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Country
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UNITED STATES
Cell Phone Number
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Home Phone Number
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User Name
Password
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Professional Information
Nickname
Texas License Number
*
Board Certifications
Specialty(s)
School and Year of Graduation
*
Degree(s)
*
Date of Birth
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Practice Information
Current Practice
*
Position
Practice Phone Number
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Practice Address
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City
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State
*
Zip
*
Country
*
UNITED STATES
Practice Fax Number
*
Employer Type
-- Please select --
01 - College or University
02 - Federal or Dominion Government
04 - State or Local Government
06 - Self-Employed Practice - Owner or Shareholder
07 - Private Practice Employee
08 - Retired
30 - Other
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State
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Zipcode/Postcode
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Country
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-- Select Country --
UNITED STATES
Name on Card
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Card Number
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Card Expiry
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2019
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CCV Number
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Amount Due:
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Lifetime Member Enrollment
Please submit this for if you are 65 years old and have been a HCVMA member for 20 consecutive years.
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