Membership Order Form

Membership Application

Complete the following form to submit your practice for inclusion on this site and any specialty sites you wish. Please note that this service is only available to licensed ND operating in Canada. Anyone submitting an order who does not appear on the list of licensed Canadian NDs will not be accepted

Personal Information:

Name:
Address:
Phone:
Email:
Website:	www.

Membership Needs:

Select all desired websites

*Website*	*Cost/Month*	*Select*
Main Site	$7.95	Mandatory
IV treatment	$1.00	Optional
Clinical Nutrition	$1.00	Optional
Asian Medicine	$1.00	Optional
Botanical Medicine	$1.00	Optional
365 Billing Option	2 months free, pay 10 months	Optional

Your Method of Payment:

Visa

Master Card

Amex

Bill Me (Only available for 365 Annual Plan)

Membership Application

Personal Information:

Membership Needs:

Your Method of Payment:

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