New Member Payment Page (online registration) | Vermont Association of Naturopathic Physicians

Membership Type(Required)

Automatically Renewed Yearly. But please know you can cancel the renewal.

Personal Information

Name

First Last

Email(Required)

Phone(Required)

Phone Type(Required)

Gender

Female

Male

Date of Birth

Personal Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Professional Information

Degree(s)(Required)

N.D. / N.M.D.

Certificate of Naturopathic Midwifery

Additional Degree(s)

M.S. Acupuncture

Other

Naturopathic School(Required)

Year of Graduation(Required)

Practice and License Information(Required)

Please list all states where you have practiced. Include all applicable ND/NMD licenses previously and currently held. If you ever had a license to practice suspended or revoked, please explain on a separate piece of paper. Please attach a CV if your practice locations below do not reflect your entire employment history since graduation.

State

Type of License

Year Licensed

License Number

Status (active, expired, revoked)

Resume (if required)

Max. file size: 50 MB.

Practice Name(Required)

Practice Phone(Required)

Practice Fax

Website

Practice Address(Required)

Street Address Address Line 2 City State ZIP Code

VANP Communication Preference

Personal address

Practice address

Online Signature(Required)

The above information is true and complete

I attest that the above information is true and complete. I understand that omitted or false information is
grounds for denial or termination of membership.

Date Signed(Required)

Online Account Registration

This will be your login for the "Find a Physician" page.

Username(Required)

IMPORTANT! This will be your user login for the "Find a Physician" page.

Password(Required)

Enter Password Confirm Password

IMPORTANT! This will be your user login password for the "Find a Physician" page.

Billing Information

Billing Address(Required)

Same as practice address

Street Address Address Line 2 City State ZIP Code

Credit Card

Card Details

Cardholder Name

Total

Consent(Required)

I understand this renewals automatically.(Required)

For the convenience of our organization, we automatically set this to renew. But please know you can cancel the renewal.

Naturopathic Principles

Naturopathic Therapies

Conditions Treated

Insurance Reimbursement

Naturopathic Principles

Naturopathic Therapies

Conditions Treated

Insurance Reimbursement

New Members Online Application & Payment Form

Personal Information

Professional Information

Online Account Registration

Billing Information

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