Class Registration Paypal – IAVSA Registration

Please complete the following application and continue through the payment portal.

Do you have an active membership? *YesNo

Are you registering for the 40 hour Certification or Recertification class? *40 Hour CertificationRecertification Class

Which class do you wish to attend? *

Name(s) of Applicants Attending *

Department or Organization *

Street Address *

Division, suite, etc

City *

State *

ZIP / Postal Code *

Email Address *

Phone Number *

Which instrument do you use?Vipre SystemsCVSA

* Disclaimer

I {name-1} {name-2} certify that all information contained in this application is complete and true to the best of my knowledge. I understand that any material omission, misrepresentation or falsification of this information is grounds for dismissal or refusal of membership to the IAVSA Association. I hereby authorize investigation of all statements contained herein and give permission to contact any or all of my previous employers, references and/or schools attended for information.

I Understand and agree to all terms Listed above

Membership Dues

Credit / Debit Card *