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Please complete (check all that apply) and mail to:

AOMSM, PO Box 775, Beverly, MA 01915

Checks made payable to: AOMSM


Membership/Annual Renewal
Full Professional Member ($150) Save = 2 years ($250)
Licensed Acupuncturists Only > Must provide MA License #

First Year Practitioner ($75)

Licensed Acupuncturists Only

Student Member Free while in School

Expected Graduation Date ____________
Corporate Sponsor (Inquire for rates at
Friend of AOMSM ($35)
Donor (Any Amount Welcome)

Please include your name, address, email address and phone number as you would
like them to appear in our database. Please print legibly
Personal Information
Name: _______________________________________________ MA License # : _____________________
Address: _______________________________________________________________________________
Phone: _____________________________________ Fax : _______________________________________
*Email: _____________________________________Website:_____________________________________

Business Information
Name: _______________________________________________MA License #: _______________________
Address: _________________________________________________________________________________
Phone: _____________________________________ Fax : _________________________________________
*Email: _____________________________________Website:______________________________________

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