APA Membership Application Form APA Membership Application Form Before completing this form please ensure you have read and understand the application process to join the APA. Don't forget to email the supporting documents to info@apa.uk.com once you have completed the Application Form.This application form has a number of questions, some of which require detailed answers. You can save the form and return to complete it at a later date if you wish. Step 1 of 5 - Personal Details and Membership Type 20% 1. Personal DetailsGender*MaleFemaleTitle*Please SelectDrMrMrsMsName First Last Date of birth* DD MM YYYY Nationality*Home Address* Street Address Address Line 2 City County Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Enter Email Confirm Email Home telephone*Mobile*2. Type of membershipType of membership*Please SelectPractitionerTherapistAssociateAffiliateFriendStudent 3. Professional Ayurvedic EducationName of the Ayurvedic course studied*Name of the institution at which you studied*Qualification Obtained*Year of course completionWas the course face-to-face or online?* Face-to-face Online Exact number of contact study hours completed*Therapists and Associate Therapists, please list the subjects covered during your study*Can you email the APA an official qualification certificate for all courses listed above?*YesNoEmail to info@apa.com after form submission.List location of clinical internshipDuration of clinical internshipDo you hold a qualification in Anatomy and Physiology at least NVQ level 3 and can provide a certificate?*YesNoEmail to info@apa.com after form submission. 4. Clinic DetailsAddress of your clinical practice* Street Address Address Line 2 City County Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Website Do you hold a practice UK registered professional indemnity insurance with specific cover for your Ayurvedic Practice?*YesNoImportant - Please note that a valid insurance is a requirement of Practitioner, Therapist and Associate Therapist membership registrations.- Associate members can be exempt from insurance requirement if they are practising as medical doctors.- Please note that all Practitioner, Therapist, Associate Therapist members must send a copy of their new certificate each year at policy renewal. - Please email your certificate to info@apa.uk.com once you have submitted this application.How long have you been practicing Ayurvedic Medicine for?*What is the area of your specialisation?*How many CPD events in the field of Ayurveda have you attended in the previous calendar year?*Please note that it is a requirement of the Associate Therapist membership to complete at least 4 CPD events each year. 5. Other professional qualificationsDo you practice as a medical doctor within the NHS in UK or a medical body in your country?*YesNoIf yes please provide details.Please list your other professional qualifications.Are you currently a member of any other professional body in the United Kingdom or abroad?*YesNoIf yes, please provide the name(s)Email to membership certificates to info@apa.com after form submission. 6. Other informationHave any past or present formal allegations of professional negligence or misconduct in relation to your practice been made, or to be made, against you by a client or patient of yours, by another professional body or in a civil court in any country?*YesNoIf yes, please provide details.Have you ever been suspended by, refused registration with, or struck off any register of another professional regulatory body?*YesNoIf yes, please provide details.Do you suffer from any physical or mental health condition that would impair your fitness to practice?*YesNoIf yes, please provide details.Are you proficient in reading, writing and speaking of the English language?*YesNoPlease let us know if you would like to offer active assistance to the organisation in the following fields Education Pharmacopoeia Ethics Public Relations Research I wish to support the APA in the following way(s)I give my permission to be added to the APA mailing list*YesNoThis is optional.Would you be interested to become part of the APA Executive Committee in the future?*YesNoPerhapsAny other commentsMembership Terms and Conditions*I have read, and I agree to abide by, the Membership Criteria and the Code of Ethics and Professional Conduct. I agree for my details to be held on the APA database, and to notify the APA should these details change. I declare that all information supplied in my application is, to the best of my knowledge and belief, true and accurate. I Accept Data Usage Consent* I consent to my data being used for this application. Date Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
