Membership Application

"*" Denotes required fields

* Your First Name

* Your Last Name

Business Name

* Your Email

* Street

* City

State

* Zip

Country

* Preferred Phone (555-555-5555)

Other Phone (555-555-5555)

Web Site (do NOT include http://)

* Please select a category of membership:
(Payment options will be offered on next page.)
 General Member Practitioner Member Professional Member Lifetime Membership

* Is this is a new membership or a renewal?
 New member! Renewal. Please send me a new certificate. Renewal. SAVE a TREE. I don't need a certificate!

* Do you wish to be listed in our online database?
 Yes - please list me No - do NOT list me

If referred by an NQA member please enter their name here:

ETHICS QUESTIONS
* All Applicants must answer the following 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 Has your malpractice insurance ever been revoked?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 "yes" to any of the above, please explain the circumstances in the box below and your application will be reviewed.

Comments?

The following questions are for Professional applicants only:
General, and Practitioner members may proceed to payment options.

Professional applicant, are you a teacher, healer, or both?
 Qigong Teacher Qigong Healer

Professional applicant, are you available to travel to teach?
 Yes No

Professional applicant, do you have Qigong books/videos for sale?
 Yes No

Professional applicant, briefly list your specialty

Professional applicant, please enter a 125 word maximum description of your service(s.) Note that terms like 'master' and 'grandmaster' are not used in the NQA and if included will be deleted from descriptions.

* Payment options:
 I intend to pay online by credit card. I will call you to arrange payment.

After completing this application, enter the security code and click Send My Application (click ONE time.) You will be redirected to the payment options page to complete your application process. Thank you!

Enter the code: