AL-AAOM Membership Application

Please complete this form and return it with payment

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AL-AAOM requires that all individual or joint members include a copy of Education,

Business License, or NCCAOM Certificate along with this application.

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Membership Category (Circle one which you are applying for):

Individual: $100.00

Friend & Student of Acupuncture& OM: $ 50.00

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First Name Middle Last Name

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Professional Title Date of Birth

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Business Name

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Street Address City State Zip

____________________ / __________________________ / ____________________

Office Phone Home & Cell Phone Web/E-mail

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Professional medical areas of expertise

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Acupuncture/TCM school attended, degrees. If you are applying as a student member, include student ID.

__________________________________ _____/_____/____

Signature Date

Amount Enclosed: $____________

* Pay by Check or Money Order, No Credit Card accepted.