*Name

Business Name

*E-mail

*Street

*City

*State

*Zip code

Home Phone

Work Phone

Fax

Website

Please select a category of membership:

Supporter $ 30.00

General Member ....$ 50.00/$ 90.00 (1 year/ 2 years)

Practitioner Member ....$ 100.00 / $ 180.00

Professional Member ....$ 150.00 $ 270.00

Lifetime Membership ....$1,250.00

If you DO NOT want your information shared please check the following:
Website   Directory   Other Organizations

If this is a renewal, click the check box if you need another certificate. 

ETHICS QUESTIONS
All Applicants must answer the following final 3 questions:

1. Are you currently under investigation or had any licensure board or professional association ever disciplined you? Yes No

2. Have you ever had your hospital privileges, license, certification, or registration suspended or revoked by any licensure board, professional association or healthcare agency? Yes No

3. Has your malpractice insurance ever been revoked? Yes No

IF you responded with a “yes” to any of the above, please explain the circumstances in the box below and your application will be reviewed.

Professional Applications (optional):

Qigong Teacher

Qigong Healer

Are you available to travel to teach? Yes No

Do you have Qigong books/videos for sale? Yes No

Catalog of items for sale? Yes No

What do you specialize in?

Professional members: Please enter a 125 to150 word description of what you teach or offer.

Comments