PrideVMC Membership Application

Membership Level: Veterinary Field Affiliation Prefix: Dr. Miss Mr. Mrs. Ms. Mx. 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I am a member of the LGBTQ+ community I am a straight ally I prefer not to identify Your Significant Other's Name: Animal Companion & Species May we refer clients to you? Yes No How did you learn about PrideVMC? School: AUBURN CAL DAVIS COLORADO CORNELL FLORIDA GEORGIA ILLINOIS IOWA State KANSAS LINCOLN MEMORIAL LOUSIANA State MIDWESTERN MINNESOTA MISSISSIPPI State MISSOURI MICHIGAN State NORTH CAROLINA OKLAHOMA State ONTARIO- Geulph OREGON OHIO STATE U PRICE EDWARD ISLAND PURDUE QUEBEC, Montreal ROSS, West Indies SASKATCHEWAN- Western College of Vet Med TENNESSEE TEXAS A & M University TUFTS- Massachusetts TUSKEGEE PENN VIRGINIA TECH WESTERN University of Health Sciences WISCONSIN WASHINGTON SU ST. GEORGES, Grenda MURDOCK, Australia SYDNEY, Austrialia MELBOURNE, Australia QUEENSLAND, Austrialia LONGON, England VETARGO, France DUBLIN, Ireland MEXICO- U.N.A. de Mexico UTRECT, The Netherlands MASSEY, New Zealand GLASGOW, Scottland EDINBURGH, Scottland IL MAS School (Other): Year of Graduation: Are you interested in mentoring students or new graduates? Yes, please contact me No Unsure, contact me. Affiliation - check all that apply Practice Name: Title: Department: Can we refer you clients? Yes No n/a Specialty: Academia Accupuncture Anesthesia Animal Welfare Avian Medicine Behavior Dentistry Dermatology Emergency and Critical Care Government Homeopathy Internal Medicine Laboratory Animal Medicine Large Animal Medicine Microbioloby Military Nutrition Ophthallmolgy Pathology Pharmacology Physician/Nurse Poultry Medicine Preventative Medicine/Public Health Radiology Rehabilitation Small Animal Medicine Student Surgery Theriogenology Toxicology Veterinary Industry Veterinary Wellness and Diversity Veterinary Association Management Wildlife Medicine Zoo Medicine Other Does your practice offer student externships? Yes, I will submit to the job board No Create a Login Name: Password: Retype Password: