Application for Membership

Name_______________________________________________________________________

Address_____________________________________________________________________

Phone
(business)_____________________(home)____________________(fax)________________
(listed on web site) (not listed)

E-mail________________________________Website________________________________
(required for Member's Only web site access)

Structural Integration Training Information

Please attach a photocopy of your certification in Structural Integration.
Please include current contact information for your school, teacher, or program.
Please additionally fill in the following:

School or program where you trained in SI_________________________________________

Location and dates of your training_______________________________________________

Date and year of certification____________________________________________________

Advanced training or continuing education________________________________________

___________________________________________________________________________

Professional References

All applicants must provide the names and phone numbers of three references who know you professionally. Two must be SI practitioners and one professional in any health-related field.

Name_____________________________________ Phone______________________________

Ethics Declaration

Have you ever been convicted of a felony in any country?_____

If so, please explain___________________________________________________________

___________________________________________________________________________

Have you ever been removed from any professional organization, lost professional privilege, membership, certification or license as a result of a standards and/or ethics violation?_____

If so, please explain___________________________________________________________

___________________________________________________________________________

I understand that IASI will make inquiries about my professional training and practices, either from professional societies, faculty, individual references, or any other individuals who may know my past or present professional activities, if such are deemed necessary. I also understand that the organization is not obligated to offer membership on the basis of this application.

I have read the IASI Code of Conduct and agree to abide by them.

If accepted, I pledge to abide by the regulations of the Association as well as to high standards of ethical practice.

I affirm that all the information in this application is true.

_____________________________________________________________________
Signature Date

Category of Membership

Professional (effect 6/1/2006) (requires copy of SI certificate and a signed, completed copy of this form)
$150US/year US members
$100US/year non-US members
Student (provide name of current SI training program and graduation date)
$50US/year
Friend of IASI (interest in SI but not a practitioner)
$50US/year

____________Amount paid with first donation
(you may deduct this from you first year membership)

____________Extra donation (please help with whatever you can)

____________Total Enclosed

Method of Payment

____Check/Cheque (payable to IASI) ____VISA/Mastercard

Please fill out the following information for credit card payments:

Name on card (please print):_____________________________________________________

Address for card:______________________________________________________________

Card #____________________________________Expiration Date:______________________

Signature_____________________________________________

PRINT, sign and mail to:

IASI • P.O. BOX 8664 • MISSOULA, MT 59807 • USA