Application Form

NIATCM Application Form

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Name

Gender

Nationality

Date of Birth

Home Phone Number

Practice Phone Number

Home Address

Practice Address

Qualification

Website URL

College Attended

Year of Graduation

Have you ever been denied Professional Membership of a Professional Association?

Have you ever been denied Professional Insurance?

Have you ever had an Insurance Claim against you?

If you answer yes to any question, please give details below

Have you ever been investigated by the Police in any country?

Are there current of issues of physical or emotional health which could impact on your practice?

Do you wish to be included on our block 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.