Instructions for Completing the Application

Personal Information
Type or print your last name (family/surname), first name and middle name. Note: The two forms of identification you present along with this application must bear the same name that appears on your application. Type or print your Social Security number or Alien Registration number. Type or print your Date of Birth (MM/DD/YY) and Place of Birth. Indicate your Gender. Type or print your mailing address. You may use your home or business address. OKAA uses the official mailing address on all correspondence. Type or print your business contact information. Enter this information if your business address differs from your official mailing address.

Website Directory Listing
Indicate which address you would like to have listed in the OKAA Directory of Certified Acupuncturists in Oklahoma. This listing is made available to the general public on the OKAA website at http://www.okacupunctureassociation.org/members.html. If you do not wish to be listed please check DO NOT LIST.

Route of Eligibility
Indicate the route of eligibility under which you are applying.

Formal Education
Type or print your school name, location, enrollment and graduation dates.

Professional Ethics and Fitness to Practice
Review the information and answer each of the questions in this section.

Occupational/Professional Licenses
Indicate all healthcare licenses you currently hold.

Professional History
Indicate all healthcare history.

Fee
Fees are due when you submit this application. Send payment to OKAA at the address listed on the bottom of the application form.

Identification
Submit all items listed. Omission of any items will constitute an incomplete application, and will be returned to sender.

Photo
Attach photo as requested.

Notarized Signature
Complete as indicated