Membership Application

Applicant Information

Member Name*

First Last

Preferred Name (nickname)

Preferred address for SDVMA correspondence*

Home
Business
They are the same

Primary Practice Information

Business Name

Business Address

Address City State ZIP Code

Business Phone

Cell Phone

Email

Business Website Address

Personal Information

Home Address*

Address City State ZIP Code

Home Phone

Date of Birth*

MM/DD/YY

Gender*

Male
Female

Spouse's Name (if applicable)

First Last

Education & Licensure Information

Undergraduate College*

Undergraduate Graduation Year*

Veterinary College*

Veterinary College Graduation Year*

SD DVM License Number

Year of SD DVM Licensing

Are you licensed in other states?*

Yes
No

Please list other states where you're licensed.

Special Areas (hunting dogs, birds, dermatology, etc.)

Board Certifications

Please indicate type of practice (select only one)*

Membership Type

Are you currently an SDVMA member and renewing your membership?*

Yes
No

Please indicate which is true

There are no changes to my information from last year.
Any changes to my information are reflected above.

Annual Membership*

Price:

Total

$0.00

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SDVMA Membership Application

Applicant Information

Primary Practice Information

Personal Information

Education & Licensure Information

Membership Type

Membership

Herd Health Conference

SDVMA Summer Meeting

SDVMA Annual Meeting