Practitioner Registration
First Name
*
Last Name
*
Email Address
*
Password
*
Confirm Password
*
Clinic Name
*
Web Address
*
Mobile
Phone
*
Education
*
Are you tax exempt?
Practitioner Type
*
---Select Practitioner Type---
Acupuncturist
Chinese Herbalist
Naturopath
Herbalist
Other
Address 1
*
Address 2
Country
*
Select Country
United States
State
*
Select State
';
Alabama
Alaska
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District of Columbia
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Washington
West Virginia
Wisconsin
Wyoming
Please select the state.
State
*
City
*
Zip Code
*
License upload
*
(file should be less than 50mb)
(
Format:
docx./pdf/png/jpeg/jpg)
License Expiry Date
*
Agree to Terms and Conditions
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