Practice Name*

Address*

City*

State* Select a StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashington D.C.Washington (State)West VirginiaWisconsinWyoming

Zip*

Phone

Email*

Website

Member of TVC
Referred by DRS

Having received payment of annual membership fee of $480, the Veterinary Care Foundation, a 501 (c) (3) charitable foundation, will create a charitable fund for the above named practice under it's charitable umbrella.

Additionally, the Veterinary Care Foundation agrees to provide veterinary practice with:

• - Foundation Brochures
• - Sample letter to practice clients
• - Website and support (allowing electronic donation of funds)
• - Member electronic access to fund balance
• - Gift acknowledgement to donors for gifts $250 and above, per IRS regulations, and electronic notification to practices for all online gifts

Dues will be renewable annually on the member’s initial application date and may be paid online, by mailing a check or by phone. If member dues are not received by renewal date, account will continue to allow donations on member’s behalf, however they will not be allowed to submit Grant Requests. Once a member has exceeded 60 days past their due date, their account login will be deactivated until brought current of all past annual dues owed to the Veterinary Care Foundation, Inc.

Authorized Representative:

User Name*

Password*

Confirm Password*