Join IAAOM

Filed under: Uncategorized — wordpress September 30, 2007 @ 8:21 pm

IAAOM is a professional organization of NCCAOM Certified and Licensed Acupuncturists. If you meet this criteria and would like to be a member, please print and complete this form and send the form along with a $100 check.

If you are in your first year as a practitioner mail the form in with a copy of your diploma showing graduation date and a check for $75 (first year out of school only).
Please make check out to: IAAOM Treasurer
Address the check to this location:

John Porter, IAAOM Treasurer
1020 East 86th St. Suite B
Indianapolis, IN 46240

Indiana Association of Acupuncture and Oriental Medicine
New Member Application

First Name____________________ Last Name_____________________

Home Address_______________________________________________

City, State, Zip______________________________________________

Home Phone_________________________________________________

Information for the Website

Office Address________________________________________________

City, State, Zip_______________________________________________

Office Phone_____________________Fax__________________________

Additional Office Address_______________________________________

City, State, Zip_______________________________________________

Phone_________________________Fax___________________________

Web Site Address_____________________________________________

E-Mail______________________________________________________

Acupuncture College Attended___________________________________

Graduation Date______________________________________________

NCCAOM Certification date______________________________________
Indiana State Acupuncture License Number_________________________

List your specialties___________________________________________

Sign here to Certify that all of the above information is correct.______________________________________________________

Welcome to our Association! We will do everything in our power to hear your voice and perform what our members determine is our agenda. Please so not hesitate to contact us with any questions and comments.