email

Phone Fax

I would be interested in being considered for an office in the IAEP Yes No

Suggested Topics / Speakers for future meetings

Note: This information will be published in a PUBLIC online directory.

Practice/University/Company Name

Practice Address

City State Zip

County

Practice email

Practice Website

Additional Attendees from your Practice to be included in the online Payment:

Name VeterinarianRegistered TechnicianAssistantStudent

email

Consider for Office? Yes No

Name VeterinarianRegistered TechnicianAssistantStudent

email

Consider for Office? Yes No

Name VeterinarianRegistered TechnicianAssistantStudent

email

Consider for Office? Yes No

Name VeterinarianRegistered TechnicianAssistantStudent

email

Consider for Office? Yes No

Name VeterinarianRegistered TechnicianAssistantStudent

email

Consider for Office? Yes No

Students: Free of Charge
Veterinarians: $75.00 each
Farriers: $75.00 each
Registered Technicians and Assistants: $55 each
Vendors: $300/meeting

Total Due: $
Note: You will need to re-enter this total in the next step.