(1) To receive your $25 rebate, please include the information regarding the new member.  ASVA will mail both parties the rebate checks once membership is approved.

I am a renewing member.  I have invited   to join.

I am a new member, (name) invited me to join.

(2) MEMBERSHIP DUES FOR 2008:

                          I will by paying by: 

Paypal     Check

Student Member (non-voting) $45 per year, enclosed, before 12/31/07 - $35

L.Ac., First Year Graduate $100, enclosed, before 12/31/07, - $90

L.Ac., Wei Qi Level $175, enclosed, before 12/31/07, - $165

Sponsor (non-L.Ac., and non-voting) $100, enclosed, before 12/31/07 - $90

 * Please consider joining with an additional contribution if you can.  Your increased support will allow us to be more successful with our community outreach and educational activities:

L.Ac. – Ling Qi Level $250

L.Ac. – Yuan Qi Level $325

No additional contribution

(3)  All L.Ac.’s must fill in:  I certify that the information given below is correct and I am currently a Licensed Acupuncturist in Virginia.
Electronic Signature (type your name)

Date

Virginia License #

Please fill in the following to receive your complete membership benefits: including ASVA website listing, listing on practitioner sheet, and more:

(4)  Please enter information for ASVA mailings and CEU course information:

Name:  

Mailing Address:          

Phone:      E-Mail     

(5)  Please enter information as you would like it to appear in the ASVA Practitioner List which is distributed to the public and is available online at the ASVA website.  (NOTE:  There is space here for up to 2 locations - let us know through email if you have additional locations)

Name:  

Designations and Degrees (such as M.Ac., Dip’l, Ac., L.Ac.)  

Business Address:  

Business Phone:         

E-Mail:     

Website:  

2nd location (if applicable)

Name:  

Designations and Degrees (such as M.Ac., Dip’l, Ac., L.Ac.)  

Business Address:  

Business Phone:         

E-Mail:     

Website:  

(6) Please check or fill in any of the following:

I have not been receiving information about ASVA CEU Events.

I or someone I know would like to make discounts available to members.

I am interested in serving on the ASVA Board.

I have an interest in political action.

Please list any topics or speakers you would like to see at ASVA events:

Any other comments you would like to make to the ASVA Board?

*Acupuncture organizations have occasionally asked the ASVA Board for our mailing and e-mail lists -- Check here if you would prefer that we NOT share your information.