CMAAC Membership Application Form

  • CMAAC Membership Application Form

    Professional Member Application
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  • EDUCATION

    College/University

  • APPENTICESHIP (if applicable)

  • POST-GRADUATE TCM AND ACUPUNCTURE TRAINING

    Internship

  • Clinic Hours/Research Fellowship

  • POST-GRADUATE TCM AND ACUPUNCTURE QUALIFICATIONS

  • TCM and/or Acupuncture License(s)

  • Continuing Education (Minimum of 15 Hours)

  • Practice History

    In chronological order, list the name of every jurisdiction where you have practiced TCM and Acupuncture, including all training appointments, since your graduation from TCM school.

  • Affiliations

    List all professional associations with which you have held or currently hold membership.

  • Questionnaire

    The following questions are to be answered yes or no. For every affirmative answer, please attach a comprehensive explanation to the application and identify the registering authority, health care facility, attending practitioner, or other institutions/persons involved in the situation.

  • Have you ever applied for a medical license, certificate of registration, or permit to practice and had such application rejected?*
  • Have you ever had medical license, certificate of registration, or permit to practice suspended, restricted, or revoked?*
  • Have you ever voluntarily surrendered your medical license, certificate of registration, or permit to practice for any reason other than avoidance of renewal fees?*
  • Have you ever, in expectation of, or during the pendency of an investigation/disciplinary proceeding, voluntarily restricted your medical license, certificate of registration, or permit to practice.*
  • Have you ever been found guilty of professional misconduct or deemed incompetent/incapacitated?*
  • Have you ever agreed to a settlement to avoid any proceeding or disciplinary action in respect to your professional conduct, competence, or capacity?*
  • Are there any criminal charges pending against you?*
  • Have you ever been charged with and/or convicted of a criminal offence?*
  • Has a court or governing body ever made a finding against you related to the practice of medicine (i.e. malpractice, failure to honour confidentiality oath, etc.)?*
  • Have you ever been withdrawn from, suspended from, or expelled from a medical school?*
  • Have you ever been withdrawn from a post-graduate training program or been suspended/removed from practice during a post-graduate training program?*
  • Are you now (or have you ever been) abusing, addicted to, or being treated for abuse/addiction to alcohol, narcotics, and/or any other controlled substance?*
  • Is there any event, circumstance, condition, or matter not disclosed in your answers to the preceding questions with respect to your character, conduct, competence, or capacity that may be an impediment to your application for membership at The Chinese Medicine and Acupuncture Association of Canada?*

  • Declaration

    I hereby certify that the above statements are true and correct to the best of my knowledge. I hereby apply for membership to The Chinese Medicine and Acupuncture Association of Canada (CMAAC). In the event of cessation of membership with CMAAC, the membership, being the property of CMAAC will be duly returned.

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  • Code of Ethics

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  • Code of Ethics Statement

  • Membership Fee

  • Please indicate how you will pay for your membership fee.

  • Cheques are to be mailed to:

    CMAAC Head Office, 154 Wellington St, London, ON N6B 2K8

     

    For e-Transfer, please contact CMAAC Head Office at headoffice@cmaac.ca or 519-642-1970.

  • Please submit:

    1. Two passport size photographs signed by a credible guarantor
    2. Certified copies of credentials (Academic and Clinical)
    3. Signed Code of Ethics
    4. Copy of Education Transcripts

    **PLEASE NOTE: The processing fee for the membership application is NON-REFUNDABLE. As well, certified copies of credentials submitted will NOT be returned.

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