Application Form – Associate Type of Membership: Associate membership (non-accredited) Student Member OR Medical Tai Chi and Qigong interest group member Refer to the membership information sheet for explanations. Profile DetailsFirstname/Given Name *Lastname/Family Name *Email Address *Date of Birth (optional)Phone *.Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabwe..Gender *This field cannot be emptyMaleFemaleOtherFor Other Gender, enter details..Please provide a brief description of your interest in Medical Tai Chi and Qigong. *Declaration and AgreementDeclaration and Agreement TermsThe information given on this form is true and correct. I make the following declarations: • I declare that I will abide by the IMTQA Code of Ethics and any applicable rules, codes and regulations. • I declare that I will abide by all applicable health fund provider terms and conditions. • I declare that I am not currently under criminal investigation. • I declare that I have not had any licensure board or professional association ever discipline me. • I declare that I have not had my hospital privileges, license, certification, or registration suspended or revoked by any licensure board, professional association or healthcare agency. • I declare that I have never had my malpractice insurance revoked. • I understand that I must pay all my subscriptions and other monies due to iMTQA until I resign my membership. If you cannot make this declaration due to a specific situation, please address the issue in an explanatory statement.Please Type Your Name *Date Signed *...Mandatory Fields ReminderPLEASE MAKE SURE ALL MANDATORY FIELDS ARE FILLED IN TO AVOID SUBMISSION ISSUES.PaymentAnnual Membership FeeYour application will not proceed without your application fee. You may also pay first year membership fees now, or wait until your application has been processed. Annual Membership Fee: US $30.00 (refundable if application does not meet the eligibility criteria) Total Payment: US $30.00 (Initial application fees plus Professional Annual membership fees) Submit ApplicationSave as Draft Note you can “Save as Draft” and come back later.
