Home
Information
About NIATCM
Acupuncture
Treatment
Conditions
Training
Find A Practitioner
Contact
Application Form
NIATCM APPLICATION FORM
Personal Details
First Name
Surname
Gender
Please Select
Male
Female
Nationality
Date of Birth
Email
Mobile No
Phone No
College Attended
Date Graduated
Practice Status
Please Select One
Currently Practicing
Starting Practice
Student
Returning to Practice
Length of Break in Service
Please Select One
None
1-2 Years
3-5 Years
6+ Years
Home Address
Practice Details
Mobile No
Phone No
Website URL
Email
Qualification
Specialised Training
Interested in Treating
Practice Address 1
Practice Address 2
Previous Association Membership
Association Name
Date Joined
Date Left
Undertakings - please answer the following:
Have you ever been denied Professional Membership of a Professional Association
Please Select
Yes
No
Have you ever been denied Professional Insurance
Please Select
Yes
No
Have you ever had an Insurance Claim against you
Please Select
Yes
No
If you answer yes to any question, please give details below
Have you ever been investigated by the Police in any country
Please Select
Yes
No
Are there current of issues of physical or emotional health which could impact on your practice
Please Select
Yes
No
Do you wish to be included on our block insurance?
Please Select
Yes
No
If you say Yes we will forward you a details of our insurance
I confirm all of the above statements to be true and there is no reason known to me why I would be considered unfit to practice a primary healthcare therapy. I agree to comply with the codes of ethics and practice of the NIATCM.
Submit
