Membership Application
Zhu¡¯s Scalp Acupuncture
Research & Education Foundation
Name________________________________________________________Gender__________
Address______________________________________________________________________
City________________________________State_______Country_________Zip_____________
Phone:Home__________________Office____________________Fax____________________
Cell__________________________E-mail__________________________________________
I wish to become a member under the category I have selected
below: (Please check one)
Payment must be made in
full at the time of application:
Enclosed is: Annual
Membership Fee
o
$100 Professional
member
o
$50 Student
member
o
$______ Support
member
Payment method:
The
3 security digits on the back of card __ __ __
Notes:
¡¤
Professional member must include a copy of current license
for practicing acupuncture.
¡¤
Student member must include a copy of current student card
or identification.
¡¤
Only members who remain active and current are eligible for
benefits.
¡¤
Members agree to follow the policies and bylaws of the association.
I certify that I have
met the requirement for the level of membership for which I am applying, and I
understand that if any
of the above is found to be incorrect or unverifiable, my membership may
be revoked.
Signature of Applicant:_______________________________________Date______________
Mail to:
ZSAREF,
Phone: 602-896-1551 Fax: 602-896-1578
_____________________________________________________________________________
Do not write in this
space (To be completed by ZSAREF)-----------------------------------------------------
Date Received_________ Amount.______________Paid
by ____________________________
Member ID. _________________