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A Holistic Healing Academy
576 Valley Road #276, Wayne NJ 07470 USA | 1-888-80-4WELL
Vickie T Eaton, Executive Director | Info@CompWellness.org

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Membership Application
May 1, 2004 - Please Email, or Printout and Mail

See Membership Section on the benefits of becoming a Member.
Offered to Qualified Practitioners, Practitioner Organizations and Complementary Healthcare Businesses
in the North America and US Territories

Please provide the following information:

Full Name, Credentials: __________________________________________________

Company Name: __________________________________________________

Email: __________________________________________________

Private Email (for internal notifications): __________________________________________________

Website: __________________________________________________

Business Address (include Postal Code): _____________________________________

Mailing Address (include Postal Code): ______________________________________

Phone (the only one published): _______________________   Fax: _____________________

Mobile: _____________________   Pager: _____________________

Education (institution, graduation date, degree/certificate): ______________________________________

              ____________________________________________________________________________

Licenses (name, state, date): ____________________________________________________________

Insurances Accepted: __________________________________________________________________

Professional Recommendation:

Member Name: _________________________________________

OR Three Professional References (no relatives or family friends, please):

Name: ________________________________   Phone: ___________________

Name: ________________________________   Phone: ___________________

Name: ________________________________   Phone: ___________________

Primary Modality (see list/description at www.CompWellness.org/eGuide/index.htm#TOC):*


Other Modalities (see list/description at www.CompWellness.org/eGuide/index.htm#TOC):*


Promotional Statement for Upgraded Website Listing
(Powerful statement about the Benefits of your business):*




Payment (in US dollars)

[   ]  Primary Care Member Practitioners with Doctorates and their Groups, Centers or Clinics $1,456   (equivalent to $3.99 per day, paid annually)

[   ]  Professional Member Practitioners, Product Suppliers, Special Services or Facilities $469   ($1.28 per day, paid annually)

[   ]  Limited Member Practitioners, Product Suppliers, Special Services or Facilities - 50% surcharge on many services $288   ($.79 per day, paid annually)

[   ]  Basic Member Practitioners, Product Suppliers, Special Services or Facilities - 100% surcharge on many services $192   ($.53 per day, paid annually)

[   ]  Supporting Member (no listings, 166% surcharge on services) $48  

[   ]  Additional one-year Membership - add 60%: $________

[   ]  $48 Discount for Associate Association Members on Professional Memberships (check yours):
[ ]ABMP  [ ]ACW  [ ]AMMA  [ ]ARC  [ ]CAMA  [ ]CAP  [ ]CMN  [ ]HANG: ($________)

[   ]  Upgrade Listing - ________ extra words over 10 @ $6 per word: $________

[   ]  Upgrade Listing - ________ highlighted: $24

[   ]  Upgrade Listing - ________ add logo: $99

[   ]  Additional Consultation _____ hours, minimum 30 minutes: $______

[   ]  Additional Services (See Marketing Materials and Services): $________

TOTAL:               $_________

Non-Profit 501(c) Organizations - 65% of TOTAL: $_________

Optional Payments for a TOTAL more than $600 (on credit cards only, no debit card or invoicing):   $_________

[  ]  monthly(15%)   [  ] bi-monthly(28%)   [  ] quarterly(39%)   [  ] 4-monthly(50%)   [  ] half year(69%)

Payment method:   [ ] Check*   [ ] Money Order*   [ ] Credit Card (AMEX only):

CC # _____________________________________ Exp Date ________

Signature _________________________________________________

Emailing Credit Card Information: For Internet email security, it is a good idea to send your card number in two parts. Simply prepare your email with part of the number, send it, then immediately send the rest of the number.

*By check or money order send to:
CompWellness Network, 576 Valley Road #276, Wayne NY 07470 USA

Latest List of Member Benefits

Home | CompWellness journal | Communications | Products | About Us | Membership | Member Info Ctr

You are wise and generous to visit our Members and Sponsors <<< Click here or the following Sponsors:
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Visitors since 5/1/1999.

*Our 1-888-7-HELP-24 health information service is free for the first 5 minutes, then 99 cents per minute on major credit card*

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