NVMA Convention Registration Form
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Registration Form Nebraska Veterinary Medical Association NVMA 119 th Annual Convention PO Box 637 Early Registration Deadline January 4, 2016 Hastings, NE 68902 Name: ____________________________________________________________________ ___DVM ___Technician ___Student Address: ___________________________________________________________________________________________________ City/State/Zip: ______________________________________________________________________________________________ Phone: _________________________________________Email:______________________________________________________ 2 ½ Day Registration Early Registration Late Registration Total by 1/4/2016 after 1/4/2016 NVMA Member or other State VMA $275 $350 ________ NVMA Life Member (No CE Credit) $ 80 $155 ________ Non – Member $425 $500 ________ 2015 Graduate & NVMA Member $ 0 $ 0 Veterinary Student $ 0 $ 0 NVMA Technician Member $130 $205 ________ Non-Member Technician $200 $275 ________ Veterinary Technician Student $ 0 $ 0 Thursday Only NVMA Member or other State VMA $135 $210 ________ Non-Member $235 $310 ________ 2015 Graduate & NVMA Member $ 0 $ 0 Veterinary Student $ 0 $ 0 Technician $ 75 $150 ________ Non-Member Technician $145 $220 ________ Veterinary Technician Student $ 0 $ 0 Friday Only NVMA Member or other State VMA $155 $230 ________ Non-Member $255 $330 ________ 2015 Graduate & NVMA Member $ 0 $ 0 Current Veterinary Student $ 0 $ 0 Technician (wetlab) $ 95 $170 ________ Non-Member Technician (wetlab) $165 $240 ________ Veterinary Technician Student $ 0 $ 0 Friday & Saturday Only NVMA Member or other State VMA $195 $270 ________ Non-Member $295 $370 ________ 2015 Graduate & NVMA Member $ 0 $ 0 Technician $ 95 $170 ________ Non-Member Technician $165 $240 ________ Continued on the next page… 1. Register one person per form. For additional registrations, please copy form. 2. Select the appropriate individual registration fees.
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To receive the Early-Bird advanced registration rate, registrations must be postmarked or received by fax, or email by January 4, 2016. Registrations received after this date will include an additional $50 late fee. Checks should be made payable to the NVMA. Payment will also be accepted by Visa, Master Card or Discover.
Transcript of NVMA Convention Registration Form
Registration Form Nebraska Veterinary Medical Association
NVMA 119th Annual Convention PO Box 637
Early Registration Deadline January 4, 2016 Hastings, NE 68902
Name: ____________________________________________________________________ ___DVM ___Technician ___Student
Address: ___________________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________
Phone: _________________________________________Email:______________________________________________________
2 ½ Day Registration Early Registration Late Registration Total
by 1/4/2016 after 1/4/2016
NVMA Member or other State VMA $275 $350 ________
NVMA Life Member (No CE Credit) $ 80 $155 ________
Non – Member $425 $500 ________
2015 Graduate & NVMA Member $ 0 $ 0
Veterinary Student $ 0 $ 0
NVMA Technician Member $130 $205 ________
Non-Member Technician $200 $275 ________
Veterinary Technician Student $ 0 $ 0
Thursday Only
NVMA Member or other State VMA $135 $210 ________
Non-Member $235 $310 ________
2015 Graduate & NVMA Member $ 0 $ 0
Veterinary Student $ 0 $ 0
Technician $ 75 $150 ________
Non-Member Technician $145 $220 ________
Veterinary Technician Student $ 0 $ 0
Friday Only
NVMA Member or other State VMA $155 $230 ________
Non-Member $255 $330 ________
2015 Graduate & NVMA Member $ 0 $ 0
Current Veterinary Student $ 0 $ 0
Technician (wetlab) $ 95 $170 ________
Non-Member Technician (wetlab) $165 $240 ________
Veterinary Technician Student $ 0 $ 0
Friday & Saturday Only
NVMA Member or other State VMA $195 $270 ________
Non-Member $295 $370 ________
2015 Graduate & NVMA Member $ 0 $ 0
Technician $ 95 $170 ________
Non-Member Technician $165 $240 ________
Continued on the next page…
1. Register one person per form. For additional registrations, please copy form.
2. Select the appropriate individual registration fees.
Meals – must select meals to receive meal ticket #attending Cost Total
Wednesday
Evening Welcome Reception ___ $0
Thursday
Business Luncheon Vegetarian meal ____ ___ $0
NVMA Banquet Ticket (select below) ___ $39 _______
10 oz New York Strip ____ North Atlantic Salmon ____ Vegetarian Meal____
Student Banquet Ticket ___ $39 _______
Friday
Lunch Vegetarian meal ____ ___ $0
Friends of the NVMA lunch, Dutch treat, need numbers ___
NVMA Social Reception ___ $0
Proceedings Notes –thumb drive $25 _______
2016 NVMA Annual Dues (must be paid to receive member registration rate)
Veterinarian $200 _______
Associate Member (lives and practices in another state) $ 65 _______
Technician $ 100 _______
Total From Above $ _______
Total From Previous Page $ _______
Grand Total $ _______
EARLY REGISTRATION IS STRONGLY RECOMMENDED
Complete the 2016 Registration Form and return it with your credit card
information or check payable to the NVMA by January 4, 2016.
We accept VISA, MasterCard and Discover
___Check is enclosed – Make payable to NVMA
___Visa ___MasterCard ___Discover
Card#__________________________________________________________________
Expiration Date:___________________3 digit Security Code__________________
Name on Card:__________________________________________________________
Billing Address:_________________________________________________________
City/State/Zip:__________________________________________________________
Return registration form to: Fax to 402-463-4705
Nebraska Veterinary Medical Assn OR with credit card information.
PO Box 637
Hastings, NE 68902
*Cancellations received on or before January 4th will receive full refund less a $50 administrative fee. No refunds will be issued for
cancellations after January 4th or for no shows.*
