Membership Form

AMERICAN HEALING ARTS ALLIANCE INC.

MEMBERSHIP FORM

Please provide the following information with your membership check.

____New member or ____Renewing member (indicate one)

Professional

____Practitioner ____Organization

General

____General Public ____Student

Benefactor (donation levels see below)

Date (mm/dd/yy) ____/____/_____

Name:___________________________________________________

Title:____________________________________________________

Company:_______________________________________________

Street Address: _______________________________________________________________________________

City:___________________________________________State:_________________ ZIP: __________________

E-Mail:___________________________________________________

Website (if professional actitioner or organization)___________________________________________________

Daytime Phone Number:______________________________________________

Evening Phone Number:______________________________________________

Please indicate if phone is home (H), work (W) or cell (C)

Membership is $36 per calendar year.

If joining after April 1 membership is pro-rated quarterly as;

$27 (April-December), $18 (July-December), $9 (October-December).