The Virginia Morticians’ Association, Incorporated

Office of the General Secretary

P.O. Box 461

McKenney, Virginia 23872

Phone:  804-469-9544   Fax:  804-469-9545

 

VMA Membership Form

 

Name  _______________________________________________________________________________

 

Mailing Address  _____________________________________________________________________

 

Street Address  _______________________________________________________________________

 

City, State and Zip Code  ______________________________________________________________

 

Email Address________________________________________________________________________

 

Firm Name  __________________________________________________________________________

 

Firm Address (if different from mailing address above)  _____________________________________

 

_____________________________________________________________________________________

 

Business Telephone Number ___________________Business Fax Number____________________

 

Home Telephone Number  _____________________________________________________________

 

Do you currently hold an active, non-restricted Virginia Funeral Service, Embalmers or Funeral Directors License? _____  Yes _____No 

 

Type of License  ________________________  License Number  ______________________________

 

District Association Membership (if none, so state) ________________________________________

 

**You must be endorsed by two VMA members in financial good standing**

 

_______________________________                                                          __________________________

Endorser                                                                                             License Number

 

_______________________________                                                          __________________________

Endorser                                                                                             License Number

 

Indicate Below The Membership Type You Are Requesting By Marking an X:

 

_______________                              VMA Only Membership                                 $ 175.00

 

_______________                              VMA & NFD&MA Membership                   $ 525.00

 

 

The undersigned, hereby makes application for membership in the Virginia Mortician’s Association, Incorporated. The applicant understands that upon approval by the VMA Board they agree to be governed by the Constitution and By-Laws of the Virginia Morticians’ Association, Incorporated.

 

 

______________________________________                                            __________________

Signature (Required)                                                                          Date