Online Membership Application

The Veterinary Hospitals Association is a group of veterinarians who own their own practices. VHA welcomes all practice owners to become members of our association. All applications need approval by the Board of Directors. Please note that some services are not available in all areas.Group purchasing is available to all members regardless of location. Cremation is limited to established VHA routes. For more information, please call the VHA at 651-451-6669.

Information about your practice

Owner's Name:
Practice Name:
Business Phone:
Business Fax:
Number of Staff:
Email Address:
Re-enter Email Address:
Web Site Address:

Mailing address:

Address 1:
Address 2:
City:
State:
Zipcode:

Business/Billing address:

Same as mailing address (leave information below blank)

Address 1:
Address 2:
City:
State:
Zipcode:

Shipping address:

Same as business/billing address (leave information below blank)

Address 1:
Address 2:
City:
State:
Zipcode:

Please indicate percent of business:

Small animal:	%
Large animal :	%
Equine:	%

Buyer Information

Who is your food buyer?
Who is your product buyer?

Business entity

Corporation (please fill in the information below)

	Name	Residential address	Phone
Shareholder:
Shareholder:
Shareholder:
Shareholder:
Shareholder:
Shareholder:

Partnership (please fill in the information below)

	Name	Residential address	Phone
Partner:
Partner:
Partner:
Partner:
Partner:
Partner:

Sole proprietor (please fill in the information below)

Sole proprietor's name:
Residential address:
Residential phone:

Do you operate under a franchise agreement?

No Yes

If yes, provide the name and address of the franchiser and all the persons who are stockholders, partners, or have any other form of ownership in the franchiser.

	Name	Residential address	Phone
Franchiser
Stockholder or partner:
Stockholder or partner:
Stockholder or partner:
Stockholder or partner:
Stockholder or partner:

Veterinarian information

Provide the names of all full-time* licensed veterinarians working at your hospital including yourself, if applicable.

Name:
Name:
Name:
Name:
Name:

*Full-time = someone who works more than 25 hours per week for not less than 40 weeks per calendar year.

Calculate fees

The membership calendar year is January to December. There is a one-time initiation fee of $100. Dues are prorated on a quarterly basis. Dues are calculated on a unit system. Your hospital or practice is one unit, and each full time (25-40 hours per week) veterinarian is considered a unit.

	Number of units	Cost
One-time initiation fee:		$100
Practice:	1
Full-time veterinarians::
	Total:	$