Practitioner Registration
First Name
*
Last Name
*
Email Address
*
Password
*
Confirm Password
*
Clinic Name
Web Address
Mobile
Phone
Education
Are you tax exempt?
Governing Organization
---Select Governing Organization---
CTCMPAO - Ontario
CTCMA - BC
CAAA - Alberta
Ctcmpanl - Newfoundland
Other - United States/Canada
Practitioner Type
---Select Practitioner Type---
Acupuncturist
Chinese Herbalist
Naturopath
Herbalist
Other
Address 1
Address 2
Country
Select Country
Australia
Belgium
Canada
France
Germany
Ireland
Netherlands
United Kingdom
United States
State
Select State
';
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please select the state.
State
City
Zip Code
License upload
(file should be less than 50mb)
(
Format:
docx./pdf/png/jpeg/jpg)
License Expiry Date
Agree to Terms and Conditions
Submit
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Terms & Conditions
