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VTAA Membership Form

This form may be printed before or after filling it out, or you may fill it out and submit it electronically.

Please note: These first 4 items are required info. Thanks.

Practitioner info:

Your First Name: (required)

Your Last Name: (required)

Your Email: (required)

Is this a renewal?: (required)
yes no 

Degrees and Titles:

Education:

Office and Contact info:

Organization Name:

Office Address e.g. Street:

Office Address e.g. PO Box:

Office City:

Office State:

Office Phone:

Home Phone (will not be listed on VTAA website):

Website:

Should we list your e-mail on the VTAA website?:
Yes No 

Office Hours:

Additional Office(s) and Office Hours:

Description of Practice:

Practice info:

Practice Includes:
Acupuncture Moxa Herbs Bodywork Qigong 

Other:

2010 Membership Fee $60 (payable to VTAA)

An electronic submittal of this form will send your info to us, you can then pay for your membership online with a credit card or paypal account. If you would prefer to send a check, please print this form and mail it with your check to:

VTAA membership
PO Box 575
Winooski, VT 05404


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