Application Form – iMTQA Professional What you are applying for:Type of Membership: Professional Membership (full certification) Provisional member (without certification) Refer to the membership information sheet for explanationsI am applying for membership to become a Certified Medical Tai Chi Qigong Instructor (CMTQI) Designation of Health Promotion in the General category *please select 1CMTQI Level 1CMTQI Level 2CMTQI Level 3CMTQ MasterHonorary CMTQ Master – Life members...In addition to the General CMTQI Designation, I am applying for Specialty Registration inArthritis CareAntenatal CareCancer CareCardiopulmonary CareDiabetes CarePain ManagementStress and Emotional WellbeingWeight ManagementWellbeing for SeniorsOther: please specify.Please Specify OtherProfile DetailsFirstname/Given Name *Lastname/Family Name *Email Address *Date of BirthPhone *.Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican 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 *.MaleFemaleOtherFor Other Gender, enter details.Details of Training and QualificationsHave you completed a Tai Chi and/or Qigong Instructor Training Course? *This field cannot be emptyYesNo..A minimum qualification is required of 250 hours, with at least 200 hours plus 50 hours teaching experience. Before you apply, check your eligibility with the membership categories and certification standards on the IMTQA website.Total Number of Hours of Training from all sources: *What is the main style of Tai Chi and/or Qigong that you learned and teach?* Specialized Styles (check all that apply) *Chen StyleSun StyleYang StyleWu StyleWu Hao StyleBuddhist GigongDaoist QigongMedical QigongMartial QigongOtherIf Other, please specifyPrimary training and highest qualificationName of your primary or current instructor, school and period you have trained in Tai Chi and/or Qigong with this instructor or school.Name of Instructor *Name of School *Address of School or WebsiteHighest Qualification Attained *Training From Date *Training To Date *...Character ReferencesReference 1 - Name *Reference 1 - Phone *Reference 1 - Email Address *Reference 2 - Name *Reference 2 - Phone *Reference 2 - Email Address *Do you have other health-related licenses and/or certifications? If so, please describeSupporting DocumentsCurriculum Vitae *Choose FileNo file chosenDelete uploaded fileCurriculum Vitae to include: (a) applied degrees, licenses, registrations, certifications, (b) a detailed description of Tai chi/Qigong education including type of instruction, area of application, hours, instructor(s), and dates, (c) a detailed description of Tai chi/Qigong teaching experience to include length of experience, setting and populations served, (d) scholarly work, if any, IMTQA Membership Application 2023 Page 3 (e) leadership roles, if any, (f) discipline-related awards, if any.Reference Letter 1 (file upload) *Choose FileNo file chosenDelete uploaded fileThree or more recommendation letters from your students and your previous Tai Chi/ Qigong teachers/mastersReference Letter 2 (file upload) *Choose FileNo file chosenDelete uploaded fileThree or more recommendation letters from your students and your previous Tai Chi/ Qigong teachers/mastersCopy of Valid ID 1 (file upload) *Choose FileNo file chosenDelete uploaded fileCopy of Valid ID 2 (file upload) *Choose FileNo file chosenDelete uploaded fileHigh quality passport sized photo (file upload) *Choose FileNo file chosenDelete uploaded fileTraining Certificates *Choose FileNo file chosenDelete uploaded fileCopy of your Tai Chi and/or Qigong training certificate(s) and/or letter(s) validating level of training from your teacher(s).Anatomy and/or clinical medicine aspects training *Choose FileNo file chosenDelete uploaded fileCopy of certification or transcript record of training in anatomy and/or clinical medicine aspects/ biomedical program.CPR Training *Choose FileNo file chosenDelete uploaded fileCopy of your current cardiopulmonary resuscitation certificate (CPR).Police History or Criminal Check CertificationDo you have any criminal history in the US or overseas? *This field cannot be emptyNoYesIf YES, you must attach a signed and dated written statement with details of your police clearance or criminal history in the US and overseas and an explanation of the circumstances.Choose FileNo file chosenDelete uploaded file..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.PaymentProfessional Membership Application 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. Initial Application Fee: US $100.00 (non-refundable) Professional Annual Membership Fee: US $295.00 (refundable if application does not meet the eligibility criteria) Total Payment: US $395.00 (Initial application fees plus Professional Annual membership fees) Submit ApplicationSave as Draft Note you can “Save as Draft” and come back later.