This form is to be completed by Naturopathic Doctors who are already members of the Michigan Association of Naturopathic Physicians. Please update your contact and business information below.

    PROFESSIONAL MEMBERSHIP RENEWAL APPLICATION

    This application is for Naturopathic Doctors who graduated from an accredited naturopathic medical program (recognized by the CNME) who hold license to practice naturopathic medicine in a state where a license is available, who are living and/or practicing in the State of Michigan, AND are already members of the Michigan Association of Naturopathic Physicians.


    Personal Information

    (Personal Information is kept private and will not be posted online.)

    Name:

    Address: Email:

    Phone: Fax:


    Business Information

    (Business Information will be posted online in the member directory.)

    Office Location 1

    Name:

    Address Line 1:

    Address Line 2:

    Email:

    Phone: Fax:

    Website:


    Office Location 2

    Name:

    Address Line 1:

    Address Line 2:

    Email:

    Phone: Fax:

    Website:



    License Information

    States/Provinces in Which You are Currently Licensed to Practice Naturopathic Medicine

    State License # Expiration date

    State License # Expiration date


    Is Your License to Practice Naturopathic Medicine in Good-Standing? YesNo

    If no, please explain


    Has your License Information Changed? YesNo

    If yes, please upload your current license below. If no, please note your license will be verified online before your renewal is completed.



    MANP INVOLVEMENT

    Are you interested in participating in one of the following MANP Committees?

    EthicsFundraisingGrassrootsLegislativeMembershipPublic RelationsNot Interested At This Time

    Email for MANP Updates if Different Than Above:


    SIGNATURE

    I agree to abide by the MANP policies and by-laws, follow its Code of Ethics, and uphold the high standards of naturopathic practice.

    Signature Date


    Please select your payment method

    I will be paying onlineI will mail in a check


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