October 2019 MAV Grad Clinical Intensive Registration October 2019 MAV Graduate Clinical Intensive October 14-19, 2019 Seating is extremely limited for MAV grads!Basic InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Is this your home or work address? Home Work PhoneCell Phone*Email Address* Title*DVMVMDState Where LicensedUpload a copy of your current veterinary license.Accepted file types: pdf, jpg, png.Scan and upload here, or you can also email your document to email@example.com.Name for Certificate of Completion (Including Degrees)*Practice Focus (check all that apply) Large Animal Small Animal Equine Exotic Other If "Other, please specify your practice focusMAV Certification Year*Upload a copy of your acupuncture certificate.Accepted file types: pdf, jpg, png.Scan and upload here, or you can also email your document to firstname.lastname@example.org. If you are an MAV graduate and cannot locate your MAV certificate, send an email and we will verify.Additional ItemsDietary ConsiderationsVegetarianVeganGluten Free / Gluten SensitiveNut/Peanut AllergiesHow did you hear about MAV Grad Clinical Intensive?* Website Friend/Co-worker School Conference Other Please indicate school, conference or explain other:ProgramPlease check track* Small Animal/Exotics Track Equine/Farm Animals Track Dual Track (Equine/Farm Animals AND Small Animal/Exotics Tracks) October 2019 MAV Grad Clinical Intensive* Price: $2,600.00 Terms and Conditions Returned Check Policy There will be a $35 fee for checks returned for insufficient funds and course will be suspended until payment clears. Cancellation Policy No refunds will be granted once you begin the modules in the Litmos Learning System. I understand that by submitting this registration form that the registration fee is non-refundable after I begin the online modules. I have read, understood, and agree to the terms and conditions herein. I further understand that by signing below, I have reviewed and agree to the terms and conditions.Type your name here to indicate that you agree to the Terms and Conditions*End User Agreement* I agree. Note: By clicking "I Agree" you acknowledge that you have read and agree to the terms set forth in the end user agreement. You must read the linked document and check the box above to continue with the form.PaymentsTotal $0.00 Will you be paying by credit card or check?*Credit CardCheck in US dollars made out to CURACORE VET (mail to CURACORE VET, 905 S Summit View, Fort Collins, CO 80524) Note: If paying by credit card, you will be asked to enter your billing address separately when checking out. If paying by check, please make payment to "CURACORE VET" and mail to: CURACORE VET 905 S Summit View Fort Collins, CO 80524 For your security, please send payment with tracking information. Questions? 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