*Home Address

*City State Zip

Spouse Name

*Home Phone

Vet School Grad Year

Facility Affiliation

Facility Name

Facility Address

City State Zip

Work Phone Other Phone Fax

*Email address

*Are you currently on the vet list? Yes No
*If not, may we submit your e-mail address to the vet list? Yes No
(Please contact the NMVMA office if you need more information regarding the vet list)

Check one if you would enjoy receiving your Roadrunner Newsletter? E-mail U.S. Mail

Which address do you prefer to be included in the directory? Home Work

Practice Type (check all that apply)

Food Animal Feline (exclusive) Equine
Mixed Practice Exotics/Wildlife Amphibians/Reptiles
Zoo Animals Laboratory Animals Companion Animals
Other

Board Certification (AVMA Recognized)