The Directory Application

1. Please provide the following contact information:

   Name	First - Middle - Last Name
   Title	Example: MD, DC, LAc
   Organization
   Street address
   Address (cont.)
   City
   State/Province
   Zip/Postal code
   Country
   Work Phone
   FAX
   E-mail
   URL

2. Business Name to be used in directory listing:
   
   
   .
3. Biography (or Organizational Description):

4. Please list your Credentials.
   
   .
   
5. Please list other Credential information (example: others in organization)
   .
   
6. Are You Certified in Auriculo Therapy?
   Yes No
   .
7. Are Others in your Organization Certified in Auriculo Therapy?
   Yes No
   .
8. If so, how many?
   
   .
9. Do you want a link to your existing website?
   Yes No
   .
10. Enter your website URL in the space provided below:
    .
11. Would you like to include a picture in your directory ad?
    Yes No     
    (If yes, we will provide you with specific information in your email acknowledgement)
    .
12. Additional Comments or Information.

    I am applying for (please check one):

Forum Membership and Directory Listing

Directory listing only

                                                

After submitting this form, you will be taken to a web page containing your information.
Please take the time to recheck it for accuracy.

You will receive additional instructions and billing information by email within 2 business days.