Abstract
Contact Information
Name__________
First M.I. Last
Clinic/Practice/Company__________
Mailing Address __________
City ________ State/Province ________
Zip/PC ________ Country ________
Work Phone (________ Fax(________
E-mail Address __________
Website Address www.________
Is the above address: □Home or □ Office
Would you like to be included in the “Find An AAFP Doctor” database that is posted on the AAFP website for public referrals? (Please note we only list practice name, address, phone, email, and website we do not list personal information.)
□Yes, include me in the database□No, do not include me in the database
Practice Type:□Feline Only□Small Animal□Mixed Large Animal□Academia□Industry□Government
Education Information
Veterinary School __________
Year of Graduation Diplomate of __________
Notice of Consent
Application for membership in the AAFP constitutes consent for the association to make you aware of products and services via fax, e-mail or mail. It also implies consent for the association to make available your name, address and other business contact information. This information is solely for other AAFP members via an on-line or printed membership directory.
Signature ________ Date ________