Membership Registration - UVMA and UAA

First name: *

Last name: *

E-mail: *

Phone: *

-
Area Code	Phone Number

Alternate phone:

-
Area Code	Phone Number

Address line 1: *

Address line 2:

City: *

Province: *

Postal Code: *

EMPLOYMENT INFORMATION

Current employer: *

Employer - Address line 1: *

Employer - Address line 2:

Employer - City: *

Employer - Province: *

Employer - Postal Code: *

Employer's Phone: *

-
Area Code	Phone Number

Employer's Fax: *

-
Area Code	Phone Number

Employer's E-mail: *

Membership: *

New Member

Renewal

Your interest in UVMA: *

Additional documentation:

UVMA's Code of Ethics

Privacy of Information

I agree to the above documents: *

Please note: Your indication that you agree to these documents
also authorizes UVMA to verify the information provided in this form
as to your employment. This agreement is the equivalent to a
signature and will be considered as such.

Application Fee - $85.00
(please confirm): *

UVMA Membership

Word Verification: