Annual Membership

Name:*

First Name Required Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Title: Title is not valid

Your Gender:* Your Gender is Required

Iwi:* Iwi is Required

Iwi (other): Iwi (other) is not valid

Mobile Phone Number:* Mobile Phone Number is Required

Medical Registration Number: Medical Registration Number is not valid

Practitioner Status: Practitioner Status is not valid

Qualifications:* Qualifications is Required

Scope of Practice: Scope of Practice is not valid

Current Place of Employment: Current Place of Employment is not valid

Current Job Title: Current Job Title is not valid

Work Address: Work Address is not valid

Work Phone: Work Phone is not valid

Work Email: Work Email is not valid

Speciality: Speciality is not valid

Specialty (Other): Specialty (Other) is not valid

Research Topics: Research Topics is not valid

University:* University is Required

University (Other): University (Other) is not valid

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Select Payment Method

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Pay Te ORA

$309.27 / Year

Terms: $309.27 / Year

	Annual Membership – Initial Payment $309.27 / Year	$309.27
	Total	$309.27

Annual Membership – Initial Payment

$309.27 / Year

$309.27

Total

$309.27