Maryland Acupuncture Society Membership Application

MARYLAND ACUPUNCTURE SOCIETY - Membership Application

Fill out the form, then print it, then press the submit button at the bottom.

Mail Completed Application and Check made out to MAS to:

PO Box 5498, Takoma Park, MD 20913-5498

Questions? call 443-320-1695 or email registrar@maryland-acupuncture.org

Personal Information First Name Last Name
Mailing Address City State Zip
Home Phone FAX Wireless Phone

The information below will be placed on the MAS web site at www.maryland-acupuncture.org.

If you do not wish have your information listed, please check this box:

Main Office Phone for Patients/Clients email
Web Site
NCCAOM certified in: Acupuncture Herbology Asian Bodywork
Acupuncture Educational Institution Graduation Year
Maryland License Number Other States Licensed In
Short Description of your Practice:

The following information is for all the offices in which you practice acupuncture:

First Office Office Name Address
City State Zip County
Phone Office Type: 1-home, 2-office bldg, 3- shared, 4-group practice:

Second Office Office Name Address
City State Zip County
Phone Office Type: 1-home, 2-office bldg, 3- shared, 4-group practice:

Third OfficeOffice Name Address
City State Zip County
Phone Office Type: 1-home, 2-office bldg, 3- shared, 4-group practice:

Select one choice below: Licensed Acupuncturist in Maryland (L.Ac)
1 year - $100 2 years - $185 1st year in practice - $75 Lifetime- $1250
Non-Maryland Licensed Acupuncturist (No voting privileges)
Out-of-State, Licensed - $100 Allied Health Care Practitioner - $100
Educational
Student - $40 Educational Institution - $75
Non-Acupuncturist, Non-Health Care Practitioner (No voting or seminar discounts)
Associate - $35

All MAS memberships new or old, expire on October 31 each year. A new member joining between May and August should take a 50% discount off the normal rates their first membership year. A new member joining after August should pay the full rate and will have their membership last until the following year. For example if you join in September 2007, your membership will expire October 31, 2008 instead of October 31, 2007.

Date Signature