DC Academy of Veterinary Medicine
Technician Remote Viewing Site Registration Form
Email form to: or Fax to 703-742-8745
NO PRE-REIGSTRATION IS REQUIRED TO ATTEND AT THE ELKS LODGE IN FAIRFAX
All technicians must complete and return this form by email or fax to pre-register to attend at a remote viewing site. This form must be completed and returned by fax ,703-742-8745, or email: by Friday before the seminar. THERE IS NO WALK-IN REGISTRATION AT REMOTE SITES!
Your credit card will be charged on the day of the seminar and you will receive an emailed receipt. If you are unable to attend the seminar and do not provide 48 hours notice prior to the seminar (e.g. by Monday 9:00 am before the seminar), a $25 administration fee will be charged to your credit card.
All fields below must be completed. Please download, complete, and return this form as an email attachment to , or fax to 703-742-8745.
NAME: (Required Field) ______)
Current DC Academy of Veterinary Medicine Technician Seminar Series Registrant (either paid or student): Yes [ ] No [ ] (If you wish to register for the series please complete/return the Series Registration Form.)
EMAIL ADDRESS: ______
Required Field: We will send seminar notes and emergency communications by email; please print clearly
Tel. Number: ______Seminar Date You Wish To Attend (mm/dd): ______
Remote Viewing Locations (Circle One)
Bowie, MD: Dogs & Cats Referral CenterGaithersburg, MD: VCA Veterinary Ref. Center
6700 Laurel-Bowie Rd. (Rte. 197)500 Perry Parkway
Leesburg, VA: The Life CentreWinchester, VA: VVERC
165 Ft. Evans Rd., NE210 Costello Dr.
Registration Fee:I acknowledge that my credit card will be charged $65: [ ]
(No Charge for Students and Seminar Series Registrants)
I acknowledge that I am a full time student, and/or that I am registered for the entire series, and will not be charged a fee to attend: [ ]
ALL registrants understand that a $25 administration fee will be charged to my credit card if I am unable to attend the seminar and do not provide 48 hours notice: Yes [ ] No [ ]
Credit Card Number: ______
Expiration Date (mm/yy: ______Security Code (3 digit number on back of card): ______
Credit Card Billing Address: ______
City: ______State: ______Zip: ______
Signature: ______Charge: $ ______