Application Form - The Association

Membership Application Form

1. Personal Details

Title

Gender

Male

Female

Date of Birth

Birth Month

Year of Birth

Nationality

First Name

Last Name

Home Address

Street Address

Address Line 2

City

County

Post Code

Country

Home Telephone

Mobile

Your Message

2. Type of Membership

Type of membership

3. Professional Ayurvedic Eduation

Name of the Ayurvedic course studied

Qualification Obtained

Was the course face-toface or online?

Name of the institution at which you studied

Year of course completion

Exact number of contact hours completed

Therapists and Associate Therapists, please list the subjects covered during your study

Can you email us an official qualification certificate for all courses listed above?

List location of clinical intership

Duration of clinical intership

Do you hold a qualification in Anatomy and Physiology at least NVQ level 3 and can provide a certificate?

Upload Certificate

Upload file(s)

4. Clinic Details

Clinic Address

Street Address

Address Line 2

City

County

Post Code

Country

Website

Do you hold a practice UK registered professional indemnity insurance with specific cover for your Ayurvedic Practice?

How long have you been practicing Ayurvedic Medicine for?

What is the area of your specialisation?

How many CPD events in the field of Ayurveda have you attended in the previous calendar year?

5. Other Professional Qualifications

Do you practice as a medical doctor within the NHS in UK or a medical body in your country?

Please provide details

Please list your other professional qualifications.

Are you currently a member of any other professional body in the United Kingdom or abroad?

Please provide the name(s)

6. Other Information

Have any past or present formal allegations of professional negligence or misconduct in relation to your practice been made, or to be made, against you by a client or patient of yours, by another professional body or in a civil court in any country?

Please provide details

Have you ever been suspended by, refused registration with, or struck off any register of another professional regulatory body?

Please provide details

Do you suffer from any physical or mental health condition that would impair your fitness to practice?

Please provide details

Are you proficient in reading, writing and speaking of the English language?*

Please let us know if you would like to offer active assistance to the organisation in the following fields

Education

Pharmacopoeia

Ethics

Public Relations

Research

I wish to support the association in the following way(s)

I give my permission to be added to the association mailing list

Would you be interested to become part of the association Executive Committee in the future?

Any other comments

Membership Terms & Conditions

I have read, and I agree to abide by, the Membership Criteria and the Code of Ethics and Professional Conduct. I agree for my details to be held on the association database, and to notify the association should these details change. I declare that all information supplied in my application is, to the best of my knowledge and belief, true and accurate.

Data usage Consent

I consent to my data being used for this application.

Date

Please Note: Before completing this form please ensure you have read and understood the application process. You can upload supporting documents via the form. You can save the form and return to complete it at a later date if you wish.

YEARLY MEMBERSHIP FEES:

Full member: £50.00
Associate members: £30.00
Student members: £20.00
Overseas members: £20.00

Membership Application Form

1. Personal Details

2. Type of Membership

3. Professional Ayurvedic Eduation

4. Clinic Details

5. Other Professional Qualifications

6. Other Information

YEARLY MEMBERSHIP FEES:

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