APPLICATION FORM FOR MEMBERSHIP OF WORLD FEDERATION OF ACUPUNCTURE-MOXIBUSTION SOCIETIES
Secretariat use only
Reg. No.:

Date Received:

Please complete this form and return it to:
WFAS Secretariat（16 Nanxiaojie, Dongzhimennei, Beijing 100700, China）

Name of applicant

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Date of Application

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Information of applicant

English Name

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Chinese Name

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Country / Region

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Date of founding

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Authorities of organization registered with:

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Total Number of Members

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Number of Doctors of Acupuncture and TCM

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Number of Western Medicine Doctors with Certificate of Acupuncture
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Number of Acupuncturists

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Number of Other Researchers or Students related with Acupuncture

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Name of President

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Term of post (Year to Year)

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Mailing Address

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Tel: ------------------- Fax: ------------------- E-mail： -------------------
Name of Liaison Person

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Mailing Address

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Tel: ------------------- Fax: ------------------- E-mail： -------------------
Permanent Mailing Address of Organization

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Tel: ------------------- Fax: ------------------- E-mail： -------------------

Web Site

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Is there any sub-parties of your society?
Yes □ No□

Name of the sub-parties
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Date -------------------

Signature -------------------

Brief Introduction to the History and Academic Activities Related to Acupuncture of the Applicant