BOIM Renewal (CAD)

Title *

First Name *

Last Name *

Address *

Address 2

City *

State/Province

Province/District/Region **Outside of North America Only**

Zip/Postal Code

Country *

Phone *

Email Address *

Membership Type *

Doctorate	Practitioner	Sabbatical
Retired or Supporting

Preferred way to contact *

Phone

Email

Any

Practitioner Level *

Please upload all scanned copies CEUs

IMD/IMP No. *

PLEASE READ

Keeping your registration current is vital and reaffirms your commitment to professionalism. It also demonstrates that you are receiving continuing education to stay atop emerging new developments in your scope of practice. Thirty (30) hours for doctors and twenty (20) hours for practitioners of CEU’s, ten (10) hours of WONM-Clinics for Humanity © activities (non-monetary), proof of professional liability insurance, and current emergency medicine certification are mandatory for renewal.

You must also attend WONM (North America) regional symposium at least once every two years.

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I have successfully completed the continuing education units (CEU) course as indicated on the enclosed documents

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I understand that the BOIM is certifying the requested designation to me to identify the services which meet the standards as set by the BOIM and WONM and must be surrendered when registration ceases or at the request of the disciplinary committee of the BOIM

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I understand that certification must be renewed membership annually to validate my position on the registry with the Board of Integrative Medicine-North America.

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I certify that the above information is correct to the best of my knowledge.

Please sign *

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