Name_________________________________________________________
Address_______________________________________________________
Phone
(business)________________(home)______________(fax)______________
Email____________________________Website________________________
Structural Integration Training Confirmation
- Please attach a photocopy of your certification in Structural Integration.
- Please include current contact information for your school, teacher, or program.
All education will be independently confirmed. - 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_________________________________________
PRINT and MAIL to: IASI, P.O. BOX 8664, MISSOULA, MT 59807, USA