The Veterinary Club - Membership

MEMBERSHIP ENROLLMENT FORM

PRIMARY MEMBER CONTACT INFORMATION:(Required to process enrollment)

Contact Last Name:

Contact First Name:

Contact Title:

E-Mail Address:

Phone #:

Practice / Association / Company:

Address 1:

Address 2:

City:

State:

Postal Code:

Website:

Office Telephone Number:

Office Fax Number:

Federal Tax ID Number:

MEMBER ELIGIBILITY: The member identified above will be eligible to participate in TVC Contracts and Programs (where no commitment document is required) within 45 days after announcement to the appropriate Supply Partner(s). Some Supply Partners require completion of specific commitment or participation forms prior to contract access. Upon receipt of these completed commitment forms, the MEMBER identified above will be eligible to participate in that specific agreement within 45 days after notification to the Supply Partner.

MEMBER TYPE (Please select one Mebmer Type)
STAND ALONE: An independent facility with no affiliatesor satellites
SYSTEM: A facility that owns, leases, and/or manages affiliates/satellites(please attach a list of facilities)
SATELITE: A facility owned, leased or managed by another TVC Member.Enter System Name or MID#:

MEMBER PRIMARY DESCRIPTION (Check one Primary Description)
Equine Practitioner
Large Animal Practice
Veterinary Medical Center - Veterinary Teaching hospital
Small Animal Practice
Small Animal Hospital and Surgery Center

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