Eg Name, town, practice

Renewal of Membership

Please complete the membership renewal form below . . .

Contact Details
Surname:
Forename:
	Male Female
Date Of Birth:
Nationality:
Home Address:
Telephone:
Mobile:
Fax:
Email:
Preferred Method of Contact	Email Post

Practice Details
Practice Address:
Practice Tel:

2nd Practice Address:
2nd Practice Tel:
	Please include my listing on the TCMCI website.

Professional Qualifications
Acupuncture:
Traditional Chinese Medicine:
Chinese Herbalism:
Others:
Please give qualification details with (e.g. Location and Years):
Full name and abbreviation of conferring:

Insurance Details
Name of Insurer:
Address of Insurer:

	I have not been nor am I currently under investigation by a police force or government agency in Ireland or abroad for an offence.

	I am currently fit to practice as an acupuncturist.

	I hereby declare that I have read the Constitution and Articles of Association and Codes of Practice and Ethics of the Association. I agree to be bound by the membership conditions as set down by TCMCI. I confirm that the above statements are true and reflect an accurate account of my experience to date.

	I have checked that my standing order is set up to go through on the 15th. September OR I have sent a cheque for €120 OR I will complete the online payment process.