MEMBERSHIP RENEWAL


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APPLICATION FOR RENEWAL OF MEMBERSHIP

FY 2007 ANNUAL DUES: $1,000
(July 1, 2007-June 30, 2008)

Name of State Board: _____________________________________________

Address: _________________________________________________________

Phone Number: (____)____-______

Email Address: _________________________________

Name of Delegate: ________________________________________________

State Contact Person: ____________________________________________

Please make check payable to "FAOMRA".
Completed Application and Check should be mailed to:

FAOMRA
c/o Penny Heisler, Treasurer
Maryland Board of Acupuncture
4201 Patterson Avenue
Baltimore, MD 21215

 

 
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