Association for Veterinary Informatics

1996 Membership Application Form

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Name: ______________________________________________    Date: _____________________

Mailing Address:

____________________________________________________   Phone: _____________________

____________________________________________________     Fax: _____________________

____________________________________________________  E-mail: _____________________

__ Change of address     __ New Membership     __Renewal ________________
                                                           membership #

                                 MEMBERSHIP LEVELS

    Level          Qualification                          Rights
___________________________________________________________________________________

__ Full        Individuals interested      Dues $35; Full voting rights; receipt
               in the field of             of newsletter; eligible for membership
               veterinary informatics      on standing committees; participation
                                           in Working Groups.

__ Associate   Individuals who support     Dues $20; No voting rights; receipt of
               the goals of the            newsletter; not eligible for membership
               Association                 on standing committees; participation
                                           in Working Groups. Limited to two years.

__ Corporate   Corporations that support   Dues $100; Full voting rights; (one per
               the goals of the            corporation); receipt of newsletter;
               Association                 not eligible for membership on standing
                                           committees; participation in Working
                                           Groups.

__ Student     Students enrolled in any    Dues $20; No voting rights; receipt of
               academic program who are    newsletter; not eligible for membership
               interested in the field     on standing committees; participation
               of veterinary informatics   in Working Groups.
___________________________________________________________________________________

Newsletter format desired: __ Hardcopy  __ Electronic ____________________  __ Both
                                                         E-mail address

Membership includes participation in one Working Group.  Please select one:

__ Practice Management Systems         __ Data and Messaging Standards
__ Communications and Networking       __ Computer-Aided Instruction/Learning
__ Computerized Patient Records        __ American Medical Informatics Association
                                                (Requires AMIA Membership)

Membership runs from 1/1/96 to 12/31/96.  Dues are payable on 1/1/96
       Make check payable to: Association for Veterinary Informatics
Mail application and dues to: Dr. James T. Case; Secretary/Treasurer, AVI;
                                  2742 Concord Ave; Davis, CA, 95616
____________________________________________________________________Revised 1/3/97
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AVI