IVTA Group Membership Request

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Please complete the following form to request Group Memberships at a Discount Rate. Once the form has been completed and received a member of the IVTA board will reach out to the clinic/facility contact with additional information for each individual to complete their membership registration. An invoice will be sent from PayPal to the contact email listed on this form. If you have any questions please reach out to IVTA.

Email *

Name of Clinic or Facility *

Clinic or Facility Mailing Address *

Clinic or Facility Phone Number *

Clinic Contact Person Email (for Invoice purposes) *

Number of Memberships Requesting *

Employee Names (First and Last) - Active Memberships

Employee Names (First and Last) - Associate Memberships

Employee Names (First and Last)- Student Memberships

Individual members may access the link to complete membership forms by going to: https://forms.gle/jGWawYtDXpRJqeTP7

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