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American Academy *f Manual Medicine.com

 

Application for Diplomate of Manual Medicine Review Testing

with the American Academy of Manual Medicine

                                                                                                                                                                       

Please complete, Print, sign and fax this application, accompanied with your Curriculum vitea.

 

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1.     Personal

 

Name

Complete Legal Name   Last                                       First                        Middle                    Professional Title

 

Previous or Maiden (if applicable)

 

Last 4 Digits of

Social Security # Date of Birth Sex  

 

Last 4 Digits of State ID or Motor vehicle operators license #

 

Address

 

City State Zip code

 

 

Phone E-Mail

 

 

2.     Business

 

Name of Business Phone

 

Business Address

 

City State Zip code

 

Web address E-Mail Address

 

Name of the National or State Certification, Registration, or Licensing Agency or Organization for my profession

 

My National or State Certification, Registration, or License#

 

Website address where Certification, Registration, or License information maybe verified

 

3.     Security

 

Your Mothers Maiden Name

 

 

 

 

 

 

I hereby attest that all the above information is correct and that my professional National or State Certification, Registration, or License is active and that if accepted

 as a Diplomate of Manual Medicine with the American Academy of Manual Medicine that I have no additional entitlements above or beyond those granted to me

by my National or State regulatory, certifying, or licensing authorities.  I give the Academy of Manual Medicine the right to verify this and any information

pertaining to my curriculum vitea (CV).

 

 

 

   I understand, accept, and agree                 Signature _______________________________