Membership Application

Biographical Information

• First Name *
• Last Name *
• Address *
  Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry
• Email *
• Phone *
• Date of Birth *This information is to let us know when to change your membership level to senior.
• Degree(s)/Licenses(s)
• Profession
• Referred to TTIA by Give name and Membership Number if possible.
• Employment/School
• Years Experience as a TT Practitioner
• Years Experience as a TT Teacher
• I would like to start a satellite chapter in my area *
  YesNo

 

Modality Information

• Modality
  If you would like your modalities to be listed in the directory, check a maximum of 4 below.AcupuntureAdministration/ManagementAlexander TechniqueAromatherapyBach Flower RemediesBiofeedbackCadiopulmonaryChinese MedicineColor TherapyCommunity Health/Public HealthConsultation/LiaisionCounselingCraniosaoralCrystal TherapyDance/Movement TherapyEducationEmergency CareFeldenkrais MethodGerontologyHealing TouchHerbologyHome CareHomopathyHospice Care/OncologyHyponotherapyImagery/VisualizationIrdologyJin ShinKinesiologyMassage TherapyMaternal and Child HealthMedical-SurgicalMeditationMidwiferyMusicNaturopathNeonatologyNeurolinguistic ProgrammingNeurologyNeurolingustic ProgrammingNeurologyNeuromuscular TherapyNurse PractitionerNutritionOrthopedicsOutpatient/Primary CarePediatricsPolarityReflexologyRehabilitationReikiRenalResearchRolfingRosen MethodShiatsu/AccupressureSOMAStaff Development/EducationStress ManagementTai ChiTherapeutic TouchTouch for HealthTrigger Point/MyotherapyTragerYogaWomens HealthPsychotheraphyMental Health

 

Application Type

• Membeship Level: *
  Seniors and Students will be required to provide documenation of current status.$45 - FIRST YEAR FULL MEMBER (Reverts to regular fees 2nd Year)$40- Agency$28 - USA Cooperative Connection Newsletter Only$35 - International Cooperative Connection Newsletter Only

 

Application Signature

• Signature *First & Last Name
• Application Date *

 

Verification

• Please enter any two digits with no spaces (Example: 12) *
• This box is for spam protection - please leave it blank