Membership APPLICATION/Renewal	
Applicant Information	
Name and Degree:     	
Hosp/Company/Institutional Affiliation (No changes? Skip to payment) :     	
Street address:     	
City:     	State:     	Country:     	
ZIP Code:     	E-mail Address:     	
Telephone:     	Fax:     	
professional Information	
Veterinary School:     	Year Graduated:     	
Board Certification:	ACVP  	ACVD  	ECVP  	ECVD  	Other Cert:      	
Societies / Organisations	AAVD  	ESVD  	ESVP  	AVMA  	ASD  	Other:     	
I am primarily a:	Diagnostic Pathologist:  	Clinical Dermatologist:  	Other:     	
I am a:	Dermatology/pathology resident in pathology or a PhD student:   (FREE)	
n.b. Residents must include a letter from their supervisor confirming residency status and providing projected date of completion of residency program.	
Payment details	
 I have enclosed a check or money order in the amount of Eighty (80) US dollars or the equivalent (based on current exchange rates) in Euros or my native currency. Checks for US dollars must be drawn on a US bank.	
am paying $80 US by:	  VISA 	  Mastercard	Signature:	
Card Number:          -              -              -                	Exp date      /     (MM/YY)	
Security code (the 3 digits on the back of the card)         	
Address where you receive your credit card statements:     	
Street address:     	
City:     	Country:     	Postal / ZIP Code:     	
 I would also like you to mail me an ISVD logo pin and have added Ten (10) dollars to my check/money order or approved credit card transaction.	

Please mail your completed form to:	ISVD
C/O Jennifer Ward, DVM
14810 15th Ave NE
Shoreline, WA 98155 USA

If paying by credit card, or you are a resident/PhD student you can also fax the form to 1-206-453-3309. For security reasons, please do not e-mail credit card info.