Practitioner Application

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Membership Practitioner Application for payment via PayPal Not paying by PayPal? Click here and fill out the form to mail or fax it in. Cost: $25/Year     Name*     Title/Degrees     Organization     Address*     City*     State*   ZIP*                          Please provide at least one contact number   Home Phone     Cell Phone     Work Phone     Email*    (e.g. jdoe@xyz.com)       What are your specialties?*     What expectations do you have in joining HMF?     How did you hear about the Health Medicine Forum? Radio program or interview TV program or interview A Health Medicine Forum Event The Health Medicine Center The website An HMF Member: Other: Please click the Continue button to proceed The information provided on this form is considered personal information, and  will be kept in the strictest confidence. Health Medicine Forum will never sell, barter or give away any of your personal information provided here.

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