WAOMA

Membership Type All One Year Memberships expire in 12 months. Annual Memberships other than the First Year Practitioner will automatically renew anually and charge the credit card on file. Annual First Year Practitioner Memberships will be charged the special rate of $100 for the first year. The membership will be automatically upgraded to Professional Member status at the end of the first year then be charged annually at the Professional Member rate. Monthly Memberships automatically renew monthly and charge charge the credit card on file.	WAOMA Professional Membership $175.00 - One Year Professional Membership $175.00 - Annual Professional Membership $14.59 - Monthly Professional Membership WAOMA First Year Practitioner $100.00 - One Year First Year Practitioner Membership $175.00 - Annual First Year Practitioner Membership (First year $100) $8.34 - Monthly First Year Practitioner Membership WAOMA Student Membership $25.00 - One Year Student Membership $25.00 - Annual Student Membership WAOMA Friend Membership $50.00 - One Year Friend Membership $50.00 - Annual Friend Membership WAOMA Institutional Membership $400.00 - One Year Institutional Membership $400.00 - Annual Institutional Membership WAOMA Silver Membership $500.00 - One Year Silver Membership $500.00 - Annual Silver Membership WAOMA Gold Membership $1000.00 - One Year Gold Membership $1000.00 - Annual Gold Membership WAOMA Platinum Membership $3000.00 - One Year Platinum Membership $3000.00 - Annual Platinum Membership
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 '_'	check for uniqueness
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