New York State Veterinary Medical Society

Member Profile: xxxxx

Prepared for REGION on DATE

Member ID: xxxxx

Membership 

Member Type: xxxxx.  

(Active member is any DVM who could potentially be a member. )

Member Status: xxxxx

Retirement Status: xxx

Expiration Date: date

Date joined: date

Contact Details

Email: xxxx

Phone: xxxx

Employer: hospital

Preferred address: preferred address

Personal Address:

Street, City, State, ZIP

Employer Address:

Street, City, State, ZIP

Education and License

Graduation Year: xxxx

Veterinary College: xxxx

License #: xxxx

Who pays dues?

Self or Employer: xxxx