You must be a member of the Student AVMA (SAVMA). Coverage starts the day following receipt of the application in our office.
Note: Please allow up to 5 business days for receipt of your personalized coverage confirmation. 

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* 1. Student First and Last Name:

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* 2. SAVMA Number:

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* 3. Email Address:

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* 4. Telephone Number:

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* 5. Address:

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* 6. City:

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* 7. State:

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* 8. Zip Code:

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* 9. School:

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* 10. Anticipated Graduation Date:

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* 11. Coverage terminates January 1, 2018.

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