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Name and degree____________________________________________________________
Hosp/Company/Institutional Affiliation__________________________________________
Street Address_______________________________________________________________
City_________________________________________________State___________________
Country___________________________________Zip/Postal Code____________________
Telephone_____________________________Fax__________________________________
E-mail address_______________________________________________________________
Veterinary School_______________________________________Year graduated_______
Board Certification: ___ACVP ___ACVD ___ECVP ___ECVD ___Other__________
Year certified______
Professional Societies/Organizations: ___AAVD ___ESVD ___ESVP ___AVMA
___ASD
Other (please list)________________________________
I am primarily a : Diagnostic pathologist ___Clinical dermatologist
___Other_________________________________
I am a : Resident in Pathology ___Resident in Dermatology___
___I have enclosed a check or money order in the amount of Sixty (60)
US dollars or the equivalent
(based on current exchange
rates) in Euros or my native currency. Checks for US dollars must be
drawn on a US bank.
___I am paying $60US by ___VISA ___Mastercard Signature____________________________
Card number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Exp
date ___/___ (.......MM/YY)
Security code (the 3 digits
on the back of the card)__ __ __ __
Address where you receive
your credit card statements_______________________________________
City_________________________Country__________________Zip/postal
code_____________
___I would also like you
to mail me an ISVD logo pin and have added Ten (10) dollars to my check/money
order
or approved credit card transaction.
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