Application Form for Membership Renewal 2022

Please note: Asterisk * indicate mandatory fields.

1). PERSONAL INFORMATION

(must match formal legal documentation)

Last Name: *
First Name: *
Middle Name:
Other names:
(used that are not part of your legal name (a.k.a., alias):)
Date of Birth (mm/dd/yyyy)
Email Address: *
(Required, as this will be the primary method of communication from the MPAA)
2). CONTACT INFORMATION

The member must notify the MPAA immediately of any change of address, name or any other information provided to the MPAA.

This address will be available to the public. P.O. Box is acceptable. The MPAA will send all mail to this address.

Address: *
City: *
Province: * Postal Code: *
Tel: * () - Fax: () -
3). PROFESSIONAL ETHICS AND DISCLOSURE

  • Have you ever been a defendant in a criminal or civil litigation connected with a health care practice?
  • Have you ever been disciplined or dismissed from membership or positions by any professional bodies?
  • Have you ever voluntarily surrendered a license to practice?
  • Have you ever been subject to complaints in relation to your practice?
  • Is there any pending inquiry or complaint with you in relation to your practice?

If you answered yes to any of the above, please provide information below. Please attach any documentation pertaining to the charge, accusations, or claims, the outcome and any remedial action taken (add extra sheets of paper as necessary)

1): Date (mm/dd/yyyy)
Nature of Event
Outcome and remedial action taken
4). PROFESSIONAL LIABILITY INSURANCE
Name of Insurance Company/Underwriter: *
Insurance Policy/Certificate Number: *
5). CONTINUING EDUCATION
(from November 1, 2020 to October 31, 2021.

5a. Please check if you attended any of the following continuing education activities provided by MPAA

1): Date (mm/dd/yyyy)
Activity name
Credit hours Attended
2): Date (mm/dd/yyyy)
Activity name
Credit hours Attended
3): Date (mm/dd/yyyy)
Activity name
Credit hours Attended
4): Date (mm/dd/yyyy)
Activity name
Credit hours Attended

Please provide details of any other continuing education activities attended/completed (including credits hours) if not provided by MPAA (for time period November 1, 2020 - October 31, 2021)

1): Date (mm/dd/yyyy)
Activity name and description
Credit hours
2): Date (mm/dd/yyyy)
Activity name and description
Credit hours
3): Date (mm/dd/yyyy)
Activity name and description
Credit hours
4): Date (mm/dd/yyyy)
Activity name and description
Credit hours
Continuing Education Requirement

MPAA requires all members to complete a minimum of 15 hours of continuing education per membership year. I confirm that I have completed a minimum of 15 credit hours of continuing education from November 1, 2020 to October 31, 2021.

5b. Have you maintained current certification in CPR?

6). FEES
The annual MPAA membership renewal fee for 2022 - 2023 is $150.
7). DECLARATION
 I declare that all the information and statements made in or submitted with this application are true, complete and correct, and I make this declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath. I also understand that misstatements or omissions of material facts may be cause for denial of this application, or for suspension or revocation of registration.
8). METHOD OF PAYMENT (due by October 31st, 2021)
E-transfer your payment to: acupunctureassociationmb@gmail.com
Please submit this form by clicking the button below or email a copy of the form to the MPAA email address above.