Please fill in
as much information as possible. Any information collected remains
private and will be used only to contact you. No information
will be sold. Thank-you.
Boxes marked with * are required.
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| *Name: |
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| *Office
Address: |
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| *City: |
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| *State: |
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| *Zip
Code: |
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| *Office
Phone: |
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| Fax: |
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| *Office
Email: |
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| Website: |
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| 2nd Office
Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Office Phone: |
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Fax: |
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| Office Email: |
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Home info is for member use only unless otherwise authorized by
owner. |
| Home Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Home Phone: |
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| Home Email: |
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States/Provinces in which currently licensed to practice
naturopathic medicine.
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*State/Province:
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| *License Number:
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| *Year Licensed:
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State/Province:
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License Number:
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Year Licensed: |
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CNME Accredited, Naturopathic Medical School Attended. |
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*School:
*Year of Graduation:
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*Are you a member
of the American Association of Naturopathic Physicans?
Yes
No |
Other current
Massachusetts Health Professional Licenses/Certificates:
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Please list
other state Naturopathic Associations of which you are a member.
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Other health
professional memberships:
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Other Academic
or Professional training: |
School/Location:
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| Years Attended:
Year Graduated/Degree:
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Please describe any areas of special interest you may have:
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Please print your name, as you would like it to appear in membership
file.
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Would you like to have you Name, Office Address, Phone
and Email listed on the MSND web site? (This only applies
to Standard Members and 1st and 2nd year Grad ND's; and only the
Office information you provided on page one of the application
will be used unless otherwise noted here.)
Yes
No |
*How interested are you in participating in the ongoing
activities of the MSND?
Highly interested = attend meetings, actively fund raise, speak
to legislators, etc.
Moderately interested = will do specific short-term tasks if given
guidance, etc.
Minimally interested = pay annual dues, etc. |
*Membership Dues(Please check one)
Standard membership (licensed ND living or working in MA) $200.00 |
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Standard (Semi-Annual payment) $115.00* |
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Associate Membership (Health Professional) $100.00 |
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1st year Graduate ND $50.00 |
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2nd year Graduate ND $100.00 |
*Please
note that there is a $15.00 service charge included in each semi-annual
payment. The balance of dues for membership is to be paid by September
1st of said year. Memberships are not prorated.
Please send copies of current license and diploma to:
MSND, Dr. Lisa Arnold, 177 Route 6A, Orleans, MA 02653 |
*
If accepted for membership in the Massachusetts Society of Naturopathic
Doctors, I agree to abide by the MSND polices and by-laws, follow
its Code of Ethics, and uphold the high standards of naturopathic
practice.
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