AACF  Application for Auriculotherapy Certification Form

NOTE:
If You are applying for Advanced Auriculotherapy Training
CLICK HERE

 ACI
PMB 270
8033 Sunset Boulevard
Los Angeles, CA 90046

 

I. Name: ____________________________________________________________________________
               First                        Middle                        Last                                (Degree for certificate, optional)

Please list your primary address to be used in the directory. 
Mail will be sent to this address unless you specify another address.

Business Name:_________________________________

 Alternate Mailing Address (if needed)
Street:________________________________________ Street:_______________________________________
City, State, Zipcode:_____________________________ City, State, Zipcode_____________________________
Phone:________________________________________ Phone:_______________________________________
FAX:_________________________________________ FAX:________________________________________
E-mail:________________________________________ E-mail:_______________________________________

II. Credential/License
____ I practice independently with a state credential/license.  Please enclose a copy of your credential / license with your application or furnish the following information:

State & Issuing Agency: ____________________________________________________________________

Field or Profession: ________________________________________________________________________

Current Credential/License No.: _____________________________________ Expiration Date: _____________


____ I do not practice independently and therefore I work under a credentialed/licensed supervisor.


III. Have you ever been disciplined or had your credential/license revoked by a disciplinary agency or are you currently
under review by a disciplinary agency? ___Yes ___No If yes, please attach a letter of explanation


IV. I am applying for certification in: 
___ All three categories,   ___Auricular Acupuncture,   ___Auriculotherapy,   ___Auricular Medicine

I have read and agree to abide by the Ethical Principles and the Policies and Procedures of the Auriculotherapy Certification
Institute (ACI), as they may be amended from time to time. I understand that review within the Institute will be the final
determination of any controversy arising between me and the Institute. If grounds exist that would permit a court to overturn or modify the Institute's action, I will seek redress only through arbitration in Los Angeles, California. I also understand that I am obligated to pay the costs of any court or arbitration proceedings including reasonable attorney's fees that are expended by the Institute in its defense where I do not prevail. I understand and agree that ACI and its affiliates assume no responsibility for my actions or activities. I practice at my own risk and hereby release ACI from any and all liability from any practice decisions I make. I hereby give permission to the Institute to contact individuals or agencies for verification of information submitted. I understand that any falsification of information is grounds for not granting or loss of Institute certification.
Signature: ___________________________________________________________________ Date: ______________

I understand that, in all circumstances, both written and practicum exam fees are non-refundable. Initial:_______Date:______

ACI does not discriminate among applicants as to age, sex, race, religion, national origin, handicap, marital status or sexual orientation. ACI has the prerogative to establish and reverse policeslprocedures including fees and dates for recertification as deemed appropriate.

Office Use only:

Applicant's Name:   Received by: Date:
Fees Received: $ __ Cash __Check # __Money Order #


 Application for Auriculotherapy Certification Form
Auriculotherapy Certification Institute
ACI
PMB 270
8033 Sunset Boulevard
Los Angeles, CA 90046