Membership Application / Voluntary Contribution
The Acupuncture & Oriental Medicine Association of New Mexico (AOMANM) is a non-profit, professional organization. Its purpose is to promote the practice of Acupuncture and Oriental Medicine as an effective and valuable component of our health-care system, and to establish excellence in the professional and ethical standards amongst its membership.
Please Complete, Print, and Submit this form along with your check made out to "AOMANM".
Thank You!

Private Contact Information:
Name: License #:
Address: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Masachusetts Michigan Minneapolis Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming West Virginia
City: State: ZIP:
Home Phone: Cell Phone:
Private E-mail:

Public Contact Information to appear on the AOMANM website:
Name:
Qualifications other than DOM:
Clinic Name:
Clinic Address:
City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Masachusetts Michigan Minneapolis Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming West Virginia ZIP:
Clinic Phone: Cell Phone: Fax:
Business E-mail: Website URL:

I would like to use AOMANM's e-mail forwarding service?: Yes / No
I would like the following e-mail forwarding address:
@AcupunctureNM.com
(Example: "Dr.JohnDoe@AcupunctureNM.com)
N.B. Your e-mail forwarding address (if you have chosen one) is the address that will appear on the website. E-mails addressed to it will be forwarded to whatever e-mail address you have specified above under "Business E-mail".

Membership Type & Fee: Professional* - $150 First Year - $50 Second Year* - $100 Lifetime Member - $1500 Student - $25 Allied Health Professional - $50 Friend or Associate - $50
*$50 minimum partial/installment payment for the Professional& 2nd Year memberships.
Contribution: $ Total Enclosed: $ Check Dated:

I would like to get involved with the work of the AOMANM. I am particularly interested in the Please Choose Education Committee Herb Committee Insurance Committee Legislative Committee Membership Committee PR Committee The Point Newsletter Website Committee committee.
I would like to volunteer for one of our most influential PR exercises - providing free treatments to NM legislators at the Roundhouse whenever they are in session.

Please make your check payable to AOMANM and send to:
AOMANM, PO Box 91293, Albuquerque, NM 87199-1293 ................Thank You!