AGV MEMBERSHIP APPLICATION FORM

SURNAME: .......................................................................................................

FORENAME: .....................................................................................................

TITLE: ................................................................................................................

DATE OF BIRTH: ..............................................................................................

GRADE: .............................................................................................................

DIVISION / AGENCY : .......................................................................................

LOCATION: .......................................................................................................

BVA MEMBER ? YES / NO*

I wish to apply for full / associate * membership of AGV. ( Full membership is only available to members of BVA ).

Signature: ............................................................................................... MRCVS

* Delete as appropriate

Please complete and return both parts of the form to:

Stewart Donald, Hon. Secretary AGV, Longman House, 28 Longman Road, Inverness IV1 1SF. Please ignore proposer/seconder as this will be addressed by Council.

BANKERS ORDER FORM

To: ..............................................................................................................................................................

( Name & Address of Member’s own bank )

Account number: ................................................ Sort code:........................................

Please pay to Barclays Bank plc, Surbiton Branch, Kingston-upon-Thames Business Centre, 6 Clarence Street, Kingston-upon-Thames, Surrey. KT1 1NY ( 20 - 46 - 73 ) for the account of The Association of Government Veterinarians ( Account No. 20122572 ) the sum of £15 (Fifteen pounds) on the first day of May each year unless otherwise notified.

Please cancel any previous standing orders payable to account 20122572.

NAME: ............................................................... Signature:............................................

( BLOCK CAPITALS PLEASE )

Date: ...................................................

ADDRESS:

............................................................................................................................................................

.............................................................................................................................................................

The completed form is to be forwarded by the Secretary, after membership has been approved, to:

Jane Clark, Hon. Treasurer AGV, Animal Health, Government Buildings, Otley Road, Leeds, LS16 5PZ

Proposed by: ........................................................................................... MRCVS

Seconded by: .......................................................................................... MRCVS