Name _______________________________________________________________________

Address (Office)_________________________                Phone # __________________

                         _________________________                 Fax # ____________________

Address (Home)_________________________                Phone # __________________

                        __________________________               E-Mail  ___________________
 
                                                                                           Website __________________
 Age _________    Marital Status ____________

Type of Practice ________ Office ________ Institute ____________

Other ___________________
                                                                 EDUCATION

Medical/Chiropractic/Osteopathic/Naturopathic School Attended: ________________________

                    Years of Attendance ___________________________________________

                    Post Graduate Training _________________________________________

                    Specialty Certification __________________________________________

                    State Boards _________________________________________________

                                                          TYPE OF MEMBERSHIP

    ______ Regular Membership                                     - Membership fee enclosed ($50)
    ______ Fasting Institute Supplement                          - Supplemental fee enclosed ($200)
    ______ Graduate Student _____________________- Membership fee enclosed ($10)
                                                   (Name of College)

I learned of the Association from: _________________________________

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                                                                       CERTIFICATION

1. I certify that I was fully educated and trained at a bona fide professional school in one of the following primary care disciplines:  Medicine, Chiropractic, Osteopathy, or Naturopathy, and

2. I am legally qualified to practice in my state or country, and

3. I am personally committed, both in philosophy and practice, to the basic principles of Natural Hygiene as substantiated in the biological sciences, and

4. I accept and agree to abide.by the Association's Principles of Ethics and Standards of Practice set forth at this Website.

(Items 1 and 2 do not apply to Graduate Students)
 

DATE:__________                                                     SIGNED: ________________________________
 

STATEMENT OF PERSONAL HYGIENIC PHILOSOPHY:

WHY I WISH TO BE A MEMBER OF THIS ASSOCIATION:

RETURN THIS COMPLETED APPLICATION TO:   MARK A. HUBERMAN
                                                                                           IAHP SECRETARY-TREASURER
                                                                                           4620 Euclid Blvd.
                                                                                           Youngstown, OH 44512
                                                                                           Phone:  (330) 788-5711
                                                                                           E-Mail:  mhuberman@zoominternet.net

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