International Association of
Medical and Therapeutic Specialists
“Uniting Innovative Healing Professionals”
Print and then mail/fax the completed application to the address at the bottom of this form.
Name
_________________________________________________________________________
* Please print your name as
it is to appear on your certificate *
Business
Name / Your Position ____________________________________________________
Mailing
Address _________________________________________________________________
City / State ______________________,__________Zip Code_________ Country ____________
Phone _________________ Fax ________________ Cell ________________ Pager
__________
Profession
_____________________________________________________________________
(*If
applying for a Registered Therapist, include two specialties you want listed on
your certificate. Here are some
examples:
All Licensed medical health care specialties; Acupuncture; Hypnotherapy; Reiki
Master Teacher; Massage Therapist; Family
Counseling; HypnoBirthing®; Neuro-linguistic Practitioner.
___________________________________________, ___________________________________
E-mail Address: _________________________________________________________________
(Please print clearly)
URL Web Address: _____________________________________________________________
(*Registered Therapists and Associate
Member/Vendors only. Please print clearly)
We encourage on-line members to post the “IAMTS Member” logo button on their website.
Are you interested in submitting original articles to the IAMTS Quarterly report? Y N
(100 – 150 words total. Longer reports can be placed on our on-line publication Therapeutic Perspectives – an IAMTS Member Digest).
Please note: Acceptance for membership is not the same as compliance with state licensing or certification. For any questions pertaining to your profession or state regulation, we suggest you contact the appropriate state regulating body.
*Registered Therapist’s acceptance requires either a state license or certification by a national organization that has been approved by IAMTS. Please list any currently held diplomas, licenses, certificates, memberships, etc.
_______________________________________________________________________________
I attest that the above information is true and accurate.
MEMBERSHIP PROGRAMS
Registered Therapist: Certificate including two specialties - suitable for framing / IAMTS lapel pin / Book publishing / Recording studio access / Web address listing / Color business cards / Discounts on Hypnostore™ items / Free discount travel club membership; auto; hotels; long distance service / and much more... $65.00
Associate Member / Vendor: A listing on our vendor's page / Offer your goods and supplies to all IAMTS members that are in conjunction with complementary healing field such as... hypnosis tapes, scripts, books, liability insurance, vitamins, herbs, etc... $45.00
Registered Therapist
/ Associate Member/Vendor
Ø
I wish to include a special donation for:
Expanding
/ Networking Membership
/ Other
___________________________
$100.00
$50.00
$25.00
$10.00
$ _______
Enclosed
check payable to: The International Association
of Medical and Therapeutic Specialists
MasterCard
Visa
Discover
American Express
Card
Holder: _________________________________________________________
Card
Number: _______________________________ Exp. Date: _______________
Signature:
___________________________________
273 E. Chicago St.
Elgin, IL 60120
Phone: 1-847-760-5000 Fax: 1-847-697-3309
Copyright ©
Last modified April 4, 2006
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