Member Application 2012

Illinois Association of Naturopathic Physicians

Member Application 2011

CONTACT INFORMATION Name: Office Name: Office Address: Office Phone: Cell Phone: Email Address: Website Address:

May we list your name on the ILANP website (www.ilanp.org)?
Yes No

May we list your contact information (office address, office phone, email address) on the ILANP website?
Yes No

May we release your membership status and contact information to third-parties such as potential patients or naturopathic professional organizations?
Yes No

Home Address: Home Phone:

What is the preferred method by which the ILANP may contact you?
Office address
Office phone
Cell phone
Home address
Home phone

QUALIFICATIONS

Did you graduate from a CNME accredited naturopathic medical school?
Yes No

When did you graduate on?
Where did you graduate from?

Please provide information about your current professional license and the state/province from which it was issued:

License Type: State: License Number: Expiration Date:

Clarification

I testify that all of the above information is true. I also agree to be contacted for the purposes of my participation in the Illinois Association of Naturopathic Physicians. I understand that my contact information may be given to the American Association of Naturopathic Physicians, or committees thereof, but will not be shared with any other organizations or entities without my prior permission.

I agree with above statement

Regular member: a licensed naturopathic doctor who graduated from an accredited naturopathic medical college, recognized by the CNME. A regular member can be eligible to become a board member and has voting rights.

Associate member: a naturopathic doctor who graduated from an accredited naturopathic medical college, recognized by the CNME, but does not currently hold an active license; or a licensed health care provider who does not claim the title naturopath, naturopathic doctor (ND), or naturopathic medical doctor (NMD) or naturopathic physician. (Includes: MD, DO, Psy.D, RN, DC, LMT, L.Ac., etc.) An associate member can attend monthly meetings, but is not eligible to vote or become a board member.

REQUIREMENTS AND DUES FOR MEMBERSHIP

Please check the box that corresponds to the type of membership you are seeking and eligible for:

REGULAR MEMBER ......................................... $250
REGULAR MEMBER – FIRST YEAR GRADUATE .... $125
ASSOCIATE MEMBER ..................................... $250
STUDENT MEMBER ........................................ $10

*Dues must be received by January 31. If you choose to pay in two installments, the first installment of 50% is due by January 31 and the second installment is due on January 31st with a postdated check for June 30th.

Please include copies of all required documents with your application:

Regular Members:
your current license to practice naturopathic medicine, AND
diploma from a CNME accredited naturopathic medical school*

Associate Members:
your license as a health care provider; OR
diploma from a CNME accredited naturopathic medical school

*You do not need to resubmit your diploma if you are renewing your current ILANP membership.

Send all documentation and a check payable to the ILANP for membership dues to:
ILANP
Preety Shah, N.D.
1736 Ariana Dr.
Bartlett, IL 60103