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Application for Membership

Signatures are required on this application.

Please type in all information on the form and when complete, "print" it to your printer so it can be signed and mailed to the address at the bottom of the application. Thank you.

Name

Degree

License Number

State

Date

Select a Membership Category from the options below:

Regular: Active

$250 per year

MD, DO, or DDS who holds a valid license to practice his/her profession in the U.S.

Regular, active membership applicants, please enclose application fee of $25.00, and a photocopy of your current license. (If you wish to enclose your dues, no application fee is required.)

In-Training Active

$150 per year

MD, DO, or DDS who participates in a valid medical, surgical, or dental training program.

Members in-training, please indicate the anticipated duration of your training and its location.

Associate

$150 per year

Advance Practice Nurse or a Physician's Assistant who holds a valid license to practice his or her profession in the U.S.

Associate membership applicants, please enclose application fee of $25.00, and a photocopy of your current license. (If you wish to enclose your dues, no application fee is required.)

Corresponding

$150 per year

A licensed foreign physician
Corresponding, (foreign) applicants, please include a copy of your license.

Student

$20 per year

A matriculant in good standing in an accredidted school of medicine, osteopathy, or dentistry with an interest in homeotherapeutics.
Student membership applications, please include copy of student I.D. card.

Credit Card

Visa MasterCard Discover

Card Number

Expires /

Signature

X___________________________________________

Professional Information

Office Address

City / State / Zip Code

Telephone Number

Fax Number

E-mail Address

Home Information

Home Address

City / State / Zip Code

Telephone Number

E-mail Address

Please List Degrees

Are you Board Certified?

yes no

Board of Certification

The AIH publishes a directory of our membership. Please indicate what of your office information should not be published. Your home information will not be published, but provided only to AIH members.

I agree to having the above office information except where indicated published in the
AIH Directory of Members and/or on the AIH website.

Signature

X______________________________________________

Applicants for Corresponding or Student membership may stop here after signing above.

Professional domestic applicants are asked to answer the following questions:

yes no

Are you prepared to practice homeotherapeutics in accordance with the AIH Standards of Practice?(see Standards)

yes no

Have you listed a physician reference?

yes no

Have you been convicted for fraud or a felony within the last five years? *

yes no

Has any action, in any jurisdiction, been taken regarding your license to practice medicine within the last five years or extending to within the last five years? This includes actions involving revocation, suspension, limitation, probation, or any other sanctions or conditions imposed upon a license.*

yes no

Have you been the subject of any disciplinary action by any medical society or hospital staff within the last five years? *

* (If you answered yes to noted questions, please attach full information.)

Conviction for fraud or a felony, or actions involving revocations, suspension, limitation, probation, or any other sanctions or conditions imposed upon a license to practice medicine or disciplinary action by any medical society or hospital staff, after due notice and hearing, may result in censure, suspension, or expulsion of a direct member. The Health Care Quality Improvement Act requires professional societies to report certain professional review actions that adversely affect membership, including denial of membership, to the National Practitioner Data Bank.

Please list a professional reference with telephone number below:

Name

Address

City / State / Zip Code

Signature

X______________________________________________

To the best of my knowledge, I have answered the above questions fully and honestly. I agree to abide by the By-Laws of the American Institute of Homeopathy, to pay all dues, fees and assessments in a timely fashion, and to conduct my practice in an ethical manner.

Signature

X______________________________________________

Office Use Only:
Date Recieved_____________	License Verification________________
Newsletter, 30 days_________________________	Journal________________________
Letter, Certificate, Membership Card______________________
Return Application to address below. Call with any questions.

American Institute of Homeopathy
101 S. Whiting St., Suite 16, Alexandria,Virginia 22304
Telephone: (888) 445-9988
Fax: (703) 548-7792