New Student Member Application Page | Vermont Association of Naturopathic Physicians

New Student Member Online Application & Payment Form

Step 1 of 4

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

Educational Information

Naturopathic Medical School(Required)

Expected Year of Graduation(Required)

Programs(Required)

License Information(Required)

Please list all states where you have practiced as a health care provider. Include all applicable 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 health care employment history.

State

Type of License

Year Licensed

License Number

Status (active, expired, revoked)

Resume (if required)

Max. file size: 50 MB.

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

Product Name(Required)

Price:

Billing Address(Required)

Same as practice address

Street Address Address Line 2 City State ZIP Code

Credit Card

Card Details

Cardholder Name

Total

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Naturopathic Principles

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