AAVSB Service Application


*Indicates required field
Personal Information *
First Name *
Middle Name
Last Name *
Suffix (Jr, III, etc)
If you might be listed under an alternate name please enter it below. This will help prevent delays in your application process.
Other Names Used?
Social Security or SI(Canada) #
eg., 123456789 		*
Please check this box if the number supplied is a Canadian SI#.
Gender
Date Of Birth
mm/dd/yyyy
*
Place Of Birth (city/state or province) *
Contact Information
 
Preferred
Home Phone
eg., 999-999-9999		    
Work Phone    
Fax    
Other Phone    
Email Address *
Re-enter Email Address *
NOTE: All our communication will come to you via EMAIL!
Address (U.S. or Canadian, if possible)
Address *
Address 2
City *
State or Province *
ZIP/Postal Code *
Country *
Alternate Address
Address
Address 2
City
State or Province
ZIP/Postal Code
Country
Special Notes
 
Service Requested








 
* AAVSB Requests your personal information including Social Security number or Canadian identification number and e-mail address for identification only. This information is not included on AAVSB reports and is not shared with other entities. Without sufficient identifiying information, AAVSB may be unable to comply with your request(s) for services.





© 2007 American Association Of Veterinary State Boards
Toll Free: (877)698.8482 Local: (816)931.1504 Fax: (816)931.1604

The information appearing on this Website is intended to provide information about the activities, programs, and services of the American Association of Veterinary State Boards. This information is ADVISORY ONLY and the visitor to this Website assumes sole responsibility for any decisions made based upon its content. AAVSB disclaims all warranties regarding such information, whether expressed or implied, including but not limited to, any warranty as to the quality, accuracy, or suitability of this information for any particular purpose.