Eastern School of Acupuncture and Traditional Medicine
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Alumni Association Membership Application

The Alumni Association is free to join and the only requirement is to complete this application and sign up to the ESATM Forum site and participate in helping, sharing, and giving to the school, the students, and fellow alumni. The ESATM Forum site has numerous areas of discussion and members can post questions, treatment concerns in their various styles of practice, or successes they may encounter through treating a particular illness or condition. Your participation in the forum and sharing your skills and abilities will enhance the success of our school, the students, and each other. Thank you in advance.
The Alumni Association

Fields in Red are required.

First Name:    Middle Initial: 
Last Name: 
Business Name: 
Home Address
Address 1: 
Address 2: 
City:   State:   Zip: 
Work Address
Address 1: 
Address 2: 
City:   State:   Zip: 
Home Phone: 
Cell Phone: 
Graduation Year:     Initial Certification/License Year:  
Current License(s): (#):     States:  
Other Degrees/License/Certifications:
Status of Practice:  Active    ( Full Time    Part Time)
   Inactive   ( Retired)
Style of Acupuncture: TCM  Japanese  Five Element
Do you practice Herbs:  Yes      No
  Other Modalities: (List): 
What would you like to see the Alumni Association be involved in: (Explain):
Are you interested in serving on a committee?  Yes      No
 If Yes, what type?
 Community Outreach Clinic
 CEU Recommendation Search Committee
 Other (Explain):
Do you have an expertise you would like to share/teach:
Do you consider your acupuncture career to be successful?
  Yes    No 
 If No, why?  
If you could, what would be one thing you would like to do, or to have done differently?
Do you attend CEU regularly or just for your recertification
Do you have a Master Teacher? If so, who is it?
Any CEU classes you would like to see at Eastern:
Other Comments Welcomed:
Please contact Kelly Williams if you need assistance with this form kwilliams@esatm.edu