Please note: Asterisk * indicate mandatory fields.
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1). PERSONAL INFORMATION
(must match formal legal documentation)
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Last Name: *
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First Name: *
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Middle Name:
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Other names:
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(used that are not part of your legal name (a.k.a., alias):)
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Date of Birth
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(mm/dd/yyyy)
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Email Address:
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(if you need to add/update your email address, Pleasae contact MPAA)
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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.
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Address: *
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City: *
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Province: *
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Postal Code: *
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Tel: *
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() -
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Fax:
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() -
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3). PROFESSIONAL ETHICS AND DISCLOSURE
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)
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1): Date
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(mm/dd/yyyy)
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Nature of Event
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Outcome and remedial action taken
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4). PROFESSIONAL LIABILITY INSURANCE
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Name of Insurance Company/Underwriter: *
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Insurance Policy/Certificate Number: *
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5). CONTINUING EDUCATION
(from November 1, 2021 to October 31, 2022)
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5a. Please provide details of any continuing education activities attended/completed (including credits hours) for time period Nov 1, 2021-Oct 31, 2022.
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1): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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2): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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3): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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4): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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5): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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6): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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7): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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8): Date
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(mm/dd/yyyy)
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Activity name and description
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Credit hours
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5b. Have you maintained current certification in CPR?
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6). FEES
The annual MPAA membership renewal fee for 2023 - 2024 is $150.
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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.
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8). METHOD OF PAYMENT (due by October 31st, 2022)
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.
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