CLEAN NEEDLE TECHNIQUE …

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 request, payable by check or credit card.

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

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