AHHA PRACTITIONER MEMBERSHIP APPLICATION


MEMBER INFORMATION:
Full Name:
(AHHA does not use Dr. in front of name. Initials for degrees & credentials may be included after name.)
Name of Business:
Street Address:
(Street address never included in listing)
City:
State:
Zip Code:
Country:
Office Telephone:
Home Telephone (optional):
(Home phone number never included in listing)
E-mail (optional):
Website (optional):

QUALIFYING CRITERIA:
Yes, I have training/certification for each of the health services I offer:
(Before your listing can be activated, AHHA must have on file where you were formally trained for each modality to be mentioned in your listing. We must have What + Where + When for EACH modality. In-progress training does not count until completed. Organizational memberships and career positions are not considered formal training.)
Degree/Certification/Course + Awarding Institution + Year Completed

(If needed, continue on separate sheet and attach OR submit in separate e-mail)

MEMBER LISTING:
Yes, you may use the following information for THE SIX LINE DESCRIPTIVE PARAGRAPH in my AHHA Practitioner Member listing.
(Keep in mind that these six lines are about 65 words or 490 characters.)
(1) Type of Practitioner:
(LIST ONE, such as Hypnotherapist, Medical Doctor, Wellness Coach)

(2) Healing Modalities offered:
(Keep in mind that online this text will be key word searchable)

(3) Key Training:
(Pick the most important ones from what you listed under QUALIFYING CRITERIA above. We will include degree/certification + institution name for as many as will fit into the listing space limitations.)

Yes, I work in partnership with my patients/clients and encourage a holistic approach to wellness.

Yes, I grant permission for release of the authorized information for the AHHA Practitioner Member networking list and other public relations opportunities.

Yes, I want to become a Practitioner Member of the AMERICAN HOLISTIC HEALTH ASSOCIATION and certify that the information I have presented above is accurate.

(signed)______________________________________________ (dated)____________________

NOTE: If you elect to submit this form using our online option, you will need to fill in the Signature box below. By typing your full name and today's date in this box you are providing the legal equivalent to your signature in response to the above questions.
SIGNATURE: (enter your full name and today's date)


CONTRIBUTION INFORMATION:
PRACTITIONER MEMBERSHIP
I support the vital work of AHHA!
The leading nonprofit wellness and healing information resource, valued by many of the foremost healthcare professionals in America.
$___60____ is my Practitioner Membership annual contribution
$_________ For foreign addresses, add $10 toward extra postage costs

[Please consider additional support]

ADDITIONAL GIFT
I understand that nonprofit AHHA remains free and impartial only through donations. In fact, AHHA's work is funded solely by contributions. Therefore, I want to contribute an additional amount to expand the outreach of this valuable organization, where people are connected with self-help resources through www.ahha.org so they can become active participants in enhancing their health and well-being. As the free and impartial wellness resource, AHHA is increasing the number of health-conscious consumers worldwide -- thus, creating more interest in what holistic healthcare professionals offer.
$_________ Along with my membership contribution, I am enclosing an additional gift
$500 Platinum Circle
$250 Gold Circle
$100 Silver Circle
$50 Bronze Circle
These extra donations over and above the basic membership contribution amount are acknowledged in the Honored Donors section of our website with the name of the donor. Gold and Platinum Circle level donors can add a hyperlink.
I grant permission to be added to the Honored Donors list
$ MY TOTAL SUPPORT TO AHHA (Membership contribution PLUS any additional donation)
AHHA is a designated 501(C)(3) - Tax ID# 33-041271
Contributions are tax deductible as allowed by law

SUBMITTAL OPTIONS
(Option 1) To pay by check, money order or credit card by mail...
Click here for form to download, printout, complete and mail in.

(Option 2) To pay by credit card using online Secure Server...
AHHA accepts Visa, MasterCard and Discover
  • Fill in ONLINE on this screen all information requested above
  • Print out a copy of all of the above for your records
  • Click on Pay Online button below
  • Follow directions to enter and submit credit card data
To pay by credit card online, click the Pay Online button below.
You will be transferred to the Authorize.net Secure Server, and asked for your credit card information.
Once you have transferred to the secure server, you will be asked to...
Enter Credit Card Number and Expiration Date
Under "Customer Billing Information"
Enter Cardholder Name and Billing Address for Card
If you enter your E-Mail Address, you will receive an immediate e-mail notification of your transaction from the credit card operation.
AHHA will acknowledge your credit card transaction by notifying you of the authorization code.

Credit Card Processing