Membership Form

    INTERNATIONAL HOMEOPATHIC MEDICAL SOCIETY
      P.O.Box 66005, Stockton, CA 95206, U.S.A.
      

                   REGISTRATION FORM

 Name ______________________________________________D.O.B._____________Age___________

Address______________________________________________Phone___________________________

City_________________________State_______________Zip______________County______________

Licenses, if any________________________________________________________________________

Years of Homeopathic Education____________Practice__________________Country______________

Schools where education in Homeopathy was received:

A.______________________________________Location_____________________________________

Degree or Diploma Earned_________________________________________Year________________

B.______________________________________Location_____________________________________

Degree or Diploma Earned_________________________________________Year________________

Application is made for Membership/Renewals/Lifetime/Fellowship____________________________

I hereby certify that the answers are correct, and that I am not in any way trying to entrap the International

Homeopathic Medical Society.

Signature_______________________________________________________Date_________________

MEMBERSHIP CATEGORIES:
There are two membership categories in the International Homeopathic Medical Society: (A) Licentiate of

Homeopathy (L.Hom.), which is awarded to those who hold a doctoral degree and have been trained in

Homeopathy, and (B) Certified homeopathic Therapist (C.H.T.), which is awarded to those who have

completed a recognized curriculum in Homeotherapeutics (Homeopathic therapy).
Homeopathic Physicians (M.D.,D.O.,H.M.D., M.D.H.,etc.)are invited to join as Licentiates of Homeopathy.

Applicants who hold at least a baccalaureate’s degree in health sciences, with advanced training in

Homeopathy, and the minimum of three years in Homeopathic research, education, or practice, may

apply for the Licentiate of Homeopathy (L.Hom.) Class B.
Members are eligible to apply for Fellowship of International Homeopathic Medical Society.
The following should be attached to the Registration Form:
Appropriate Fee, Copies of all testimonials, Recent Photograph of yourself, CV of yourself.
Application fee $50/-, Membership fee $ 175/- Renewals $ 50/-,Lifetime fee $ 500/-,
Fellowship fee $ 500/-
SECTION 2
For  Payments by Credit Card :
Amount of payment $_______ Mastercard ___Visa___ Maestro___  American Express___ .

Start date___________ Expiry date___________
Card no __________________________ Issue no (Maestro cards)____________________________

Personal Identification Number(as on the card)_____________________

Signature ______________________________ Name (on card) ______________________________

Address (if different from Section one) ___________________________________________________