Associate Membership Application

"*" indicates required fields

What Are You Applying For Today?

Application Type*

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Fax

Membership Qualifications

Have you been an associate member with the MAND previously?

Yes

If no, please include a detailed message on why you would like to be an associate member of the MAND. If you are already sponsored by a member, please include the member's name here.

Business Information

Upon membership approval, associate members may choose to have their business listed on our website as MAND supporting businesses. This is a new feature which will be live in the near future.

Office Location 1

Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Website

Add Second Office Location?

Office Location 2

Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Upload a copy of your professional license

Accepted file types: pdf, docx, doc, Max. file size: 512 MB.

This is required for business screening before being listed on our website.

Has your professional license ever been suspended or revoked in any state?*

If yes, please explain*

Postgraduate training in naturopathic medicine (residencies, internships)

Professional References

Reference One

Name*

Address*

Phone*

Reference Two

Name*

Address*

Phone*

MAND Involvement

Are you interested in participating in any of the following MAND committees?*

Ethics

Fundraising

Grassroots

Legislative

Membership

Public Relations

Not Interested At This Time

Submit

If accepted for membership in the MAND, I agree to abide by the MAND policies and by-laws, follow its Code of Ethics, and uphold the high standards of naturopathic practice.

Signature*

Date*

Please select your payment method*

Name

This field is for validation purposes and should be left unchanged.

Associate Membership Application

What Are You Applying For Today?

Personal Information

Membership Qualifications

Business Information

Professional References

MAND Involvement

Submit

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