Doctor MembershipDoctor MembershipDoctor$150.00Graduate of an accredited ND school or other medical program. Has access to all member features & directories PLUS public listing.Select Your Payment CycleYearlyNextPreviousMembership ApplicationPersonal Details*First Name * First NameFirst Name can not be left blank.Please enter valid data.This first name is invalid. Please enter a valid first name.*Last Name * Last NameLast Name can not be left blank.Please enter valid data.This last name is invalid. Please enter a valid last name.*Email Address * Email AddressEmail Address can not be left blank.Please enter valid email address.Please enter valid email address.This email is already registered, please choose another one.This will be your login username*Password * PasswordPassword can not be left blank.Please enter valid data.Please enter at least 6 characters.Strength: Very Weak*Full Name * Full NameThis field can not be left blank.Please enter valid data.How your name will appear to other membersHeadshot photo Headshot photoDrop file here or click to select.Please select file.Invalid file selected.Invalid file selected.Please upload a headshot*About You * About YouBiography can not be left blank.Please enter valid data.Please provide a brief bio (visible to other members)Public Email Public EmailText field can not be left blank.Please enter valid data.Visible to other membersPublic Phone # Public Phone #Text field can not be left blank.Please enter valid data.Visible to other members*Your Mailing Address * Your Mailing AddressText field can not be left blank.Please enter valid data.Street, City, ZIP (Will remain private)Education Details*Accredited School Name * Accredited School NameText field can not be left blank.Please enter valid data.*Graduation Year * Graduation YearField can not be left blank.Please enter valid year.Please enter at least 4 characters.Maximum 4 characters allowed.Please enter valid year.*Are you licensed as an ND in another state?YesNoPlease select one option.Please enter valid data.If, yes, which state? If, yes, which state?Text field can not be left blank.Please enter valid data.Please enter valid data.License # License #Text field can not be left blank.Please enter valid data.List professional licenses you hold. List professional licenses you hold.This Field can not be left blank.Please enter valid data.Please specify when licensed and where.Practice InfoPractice Name Practice NameText field can not be left blank.Please enter valid data.Practice Description Practice DescriptionThis Field can not be left blank.Please enter valid data.Practice Specialties Practice SpecialtiesText field can not be left blank.Please enter valid data.Separate each by commaPractice City Practice CityText field can not be left blank.Please enter valid data.Practice Website (URL) Practice Website (URL)Website (URL) can not be left blank.Invalid URLInvalid URLPractice Phone # Practice Phone #Text field can not be left blank.Please enter valid data.Does your practice have a residency program?YesNoPlease select one option.Please enter valid data.Certification*Please upload a copy of diploma from accredited Naturopathic Medical school or copy of current Naturopathic Medical License * Please upload a copy of diploma from accredited Naturopathic Medical school or copy of current Naturopathic Medical LicenseDrop file here or click to select.Please select file.Invalid file selected.Invalid file selected.SocialsFacebookFacebookTwitterTwitterLinkedInLinkedInInstagramInstagramcropSkip(Use Cropper to set image and use mouse scroller for zoom image.) Select Your Payment GatewayPaypalHow you want to pay? Auto Debit Payment Manual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Coupon Discount Amount : , Final Payable Amount: Submit
