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Membership Application Form
American Academy of Medical Acupuncture
(Please print out this form, complete it, enclose the required documents with payment and send to the address at the bottom of this page.)
NOTE: Use additional sheets of paper if necessary.
Name: ____________________________________________________________
Date of Birth: _______________________________________________________
Office Address: ________________________________________________
City/State/Zip Code: _________________________________________________
Phone: __________________________________
FAX: ___________________________________
Email: _______________________________________________
Home Address: ________________________________________________
City/State/Zip Code: ____________________________________________
Phone: _______________________________
FAX: _________________________________
Email: __________________________________________
SPECIALTY: __________________________________________________
SUBSPECIALTIES:______________________________________________
EDUCATION/DEGREES:_______________________________________
Medical School: ____________________________________________________
Internship: _________________________________________________________
Residency: ________________________________________________________
Post Graduate: ____________________________________________________
Medical Licensure (State and Number): ____________________________
HOSPITAL AFFILIATION:
1. __________________________________________________________________
2. __________________________________________________________________
Type of Current Practice: _______________________________________________
Years of Current Practice: ____________________________________________
Membership in Acupuncture Organizations: _______________________________
Membership in Other Medical Organizations: _____________________________
Teaching Appointment: ______________________________________________
Publications: ______________________________________________________
FORMAL COURSES (Please give Title, Sponsoring Organizations, Address,
Hours and Dates of each course completed):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
PRECEPTORSHIPS (Please give Name, Address, and Dates and describe
each position in detail):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
ACUPUNCTURE PRACTICAL EXPERIENCE (Please describe in detail
years of experience, type of problems, number of patients per week, results):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
IMPORTANT NOTE:
Check that the following documents are enclosed with your application:
1. A copy of Active State License.
2. Certificate of Training in Acupuncture
3. Active Duty Military: Provide documentation of military status
4. Students: Provide documentation of current status as medical student or medical resident.
Application fees and Status:
(See Membership Information about categories.)
Indicate which Membership Status you are applying for below.
1. Full Membership $315
2. Associate Membership $315
3. Active Duty Military Personnel $135
4. Application Fee $150 - Required only with Full or Associate Membership Applications
5. Affiliate Membership $135
6. International Affiliate $135
7. Student Membership $75
- Make check payable to: American Academy of Medical Acupuncture
MAIL completed application, payment and materials to:
Director of Membership
American Academy of Medical Acupuncture
1970 E. Grand Ave.
Suite 330
El Segundo, CA 90245
(310) 364-0193
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