This form may be printed before or after filling it out, or you may fill it out and submit it electronically.
Please note: These first 4 items are required info. Thanks. First Name: Last Name: E-mail : Is this a renewal? Yes No If "No", or if you're renewing but have changes to make in your info, please fill out the rest of this form
Organization Name:
Office Address: Address (e.g. Street): Address (e.g. PO Box): Office City Office State Vermont New York New Hampshire Zip:
Office Phone: Home Phone (will not be listed on VAAOM website):
Website: Should we list your e-mail on the VAAOM website? Yes No
Office hours:
Additional Office(s) and Office Hours:
Description of Practice:
Practice Includes: Acupuncture Moxa Herbs Bodywork Qigong
Other:
2010 Membership Fee – $60 (payable to VAAOM)
An electronic submittal of this form will send your info to us, and then take you to our payment page, where you can pay for your membership online with a credit card or paypal balance. If you would prefer to send a check, please print this form and mail it with your check to:
