WAOMA

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M E M B E R S H I P T Y P E *	Professional Practitioner Memberships	Basic Membership, annual, $175, expires in one year
		Basic Membership, monthly, $14.59, auto renewal
		Basic Membership Plus, monthly, $25.00, auto renewal
		Basic Membership Junior, First-Year Practitioner, monthly, $8.34 first 12 mos., $14.59 thereafter, auto renewal
	Student and Friend Memberships	Student Membership, annual, $25, expires in one year
	Student and Friend Memberships	Friend (Non-Practitioner) Membership, annual, $50, expires in one year
	Sponsorships	Institutional Sponsorship, annual, $400, expires in one year
		Institutional Sponsorship, monthly, $33.34, auto renewal
		Silver Sponsorship, annual, $500, expires in one year
		Silver Sponsorship, monthly, $41.66, auto renewal
		Gold Sponsorship, annual, $1,000, expires in one year
		Gold Sponsorship, monthly, $83.33, auto renewal
		Platinum Sponsorship, annual, $3,000, expires in one year
		Platinum Sponsorship, monthly, $250, auto renewal
	One-Time Donations (For Members and Non-Members)	$50
		$100
		$200
Payment System *		PayPal Pay with PayPal Credit Card Pay by credit card
Your Name * Your First & Last name
Your E-Mail Address * A confirmation email will be sent to you at this address
Choose a Login Name (User ID) * It must be 4 or more characters in length and may only contain small letters, numbers, and the underscore '_'
Choose a Password * Must be 4 or more characters
Confirm your password * Enter password again
Primary Clinic Name
Primary Clinic Address Street Address Only
Primary Clinic City
Primary Clinic State
Primary Clinic Zip Code Five digit postal code
Primary Clinic Phone Please include area code!
Primary Clinic Fax
Secondary Clinic Name Leave blank if not applicable
Secondary Clinic Address
Secondary Clinic City
Secondary Clinic State
Secondary Clinic Zip Code Five digit postal code
Secondary Clinic Phone Please include area code!
Secondary Clinic Fax
Practice Focus - Disorders Choose as many as apply:		Allergies Sinus Cancer Adjunct Therapy Childrens Health - Pediatricians Dermatology Digestive Disorders - Irritable Bowel Emotional Balance Fibromyalgia - Chronic Fatigue Headache - Migraine Heart - Cardiac Internal Medicine Mens Health Musculoskeletal Disorders Pain Relief Psycho-Spiritual Imbalance Respiratory - Asthma Seniors Health Womens Health Fertility
Practice Focus - Specialties Choose as many as apply		Addictions / Detox Automobile Accidents Chinese Herbal Medicine Cosmetic Acupuncture Exchange of Services Possible House Calls Insurance Billing Nutrition Sliding Scale See Link to Practitioner website Time of Service Discounts Weight Management
Acupuncture License Number
In practice since...
WAOMA Referrals Please check to approve having your practice listed for referrals from the WAOMA website.		YES NO
Vendor Emails Please check here to approve receiving occasional mailings or emails from vendors of acupuncture supplies and related products		YES NO
School What school are you currently attending? (student members only)
Expected Graduation Date (student members only)
Your Business Web Url? example: http://www.waoma.org
Offer Preceptorship? Check if you have been in practice for at least 5 yrs and would be open to offering an observational preceptorship to an acupuncture student		Yes No
Voting Street Address
Voting Zip Code

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