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Practitioner Sign Up Form

Please fill out the form below. You will then be directed to our secure server (paypal) to make a payment via credit card. If you'd like to get the discounted rate, please include either your: a. proof of membership for the AAOM, AOM or your state organization (in the form of your membership number or a contact place for verification); b. an address where you have a link on your site to either of my sites (www.tcmstrategies.com or www.tcmstudent.com).

The red stars mean that field is required.

*Name & Title

Business / Practice Address

City State Zip

Office Phone Fax

Web Address

*Email

Graduated From

Style(s) Practiced

Specialties

Comments / Proof