Please print out this form, sign it, and mail it with the application
AFFIDAVIT
I, _________________________________________________________
hereby affirm that I have practiced a minimum of two years in
clinical medical acupuncture since completion of my formal,
basic medical acupuncture training (a 200 hour training program).
I further affirm that I have completed at least 500 medical
acupuncture treatments. My medical acupuncture practice involves
more than one of the following acupuncture paradigms including,
but not limited to, energetic acupuncture, neuroanatomic acupuncture,
5 Elements, TCM, Auricular, Scalp, Hand, etc.
Signature ____________________________________
Date ____________________
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