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Application for a Qigong Institute Public Access Page

Please provide information you would like the public to know about you and your services. Answer the questions concisely and accurately. You may leave blank those questions that do not apply. Follow the format so that members of the public can make comparisons.

Notes:

* = Mandatory field
** = Five words or less

Personal information:

First Name*:

Last Name*

Middle initial:

Address information:

Address 1*		State*:
Address 2		Zip (postal) code*:
City*		Fax number
Country*		Phone number
Region if outside USA*:		E-mail address*:

Practice information:

Institution:

URL of your web page:

Principal services - Teaching (e.g., qigong , TaiChi, yoga, spiritual, KungFu, etc.) **

Member of the Qigong Institute ?

Yes No

Principal services - Therapy (e.g., qigong, massage, therapeutic touch, Reiki, etc.) **

Link URL to the List of Qigong professionals?

Yes No

Describe your practice and services in about one page. If possible, include literature/flier relating to your practice.

Educational background:

Subject:		Academic degrees & year:
Where:		Training (describe briefly: medical, qigong, TaiChi, other):
When:

Type of listing:

	Free
	Paid