Name_________________________________________________________

Address_______________________________________________________

Phone
(business)________________(home)______________(fax)______________

Email____________________________Website________________________

Structural Integration Training Confirmation

1. Please attach a photocopy of your certification in Structural Integration.
2. Please include current contact information for your school, teacher, or program.
   All education will be independently confirmed.
3. 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___________________________________________

____________________________________________________________________________

Category of Membership

• Professional (requires confirmation of SI training completion)
  $150/year (US, UK, Europe)
  $100/year (Austrialia, New Zealand, Canada, and Japan)
  $75/year (South and Central America)
• Student (provide name of current SI training program)
  $50/year
• Friend of IASI (interest in SI but not a practitioner)
  $50/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

On-Line Application Form   ____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_________________________________________