CLEAN NEEDLE TECHNIQUE …

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Council of Colleges of Acupuncture and Oriental Medicine PO Box 65120, Baltimore, MD 21209 Phone: (410) 464-6040 Fax: (410) 464-6042 Email: CLEAN NEEDLE TECHNIQUE CERTIFICATE/VERIFICATION REQUEST FORM Name: ________________________________________ __________ Birthdate (required):_____________________ Email address (required): ________________________________________ ___________________________________ Current Address: ________________________________________ ________________________________________ _ City: _______________________________________ State: ______________________ Zip: ________________ Country: ______________________________ Phone Number: ________________________________________ __ Date of CNT course (approximate date is acceptable if exact date is unknown): ______________________________ Location of CNT Course (city/state): ________________________________________ __________________________ ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- -------- PAYMENT INFORMATION: There is a $10 fee per req

Council of Colleges of Acupuncture and Oriental Medicine PO Box 65120, Baltimore, MD 21209 Phone: (410) 464-6040 Fax: (410) 464-6042 Email: pdiamond@ccaom.org