AC66 Returning Warrior Application | Helms Medical Institute

Medical Acupuncture for Physicians
Returning Warrior Application

Tempe Mission Palms Hotel, Tempe, AZ
Introductory Unit: 12-16 December 2019
Clinical One: 14-18 February 2020
Clinical Two: 20-24 May 2020

If you are a graduate of the basic MAFP course with a graduation date of May 2018 and later, you may select the clinical unit(s) you wish to attend. If you graduated prior to this date, you may be requested to register for all three live units due to evolving course curriculum. Contact HMI to discuss your situation and goals.

In addition to completing the application form below, a photocopy of your current medical license is required for your application to be considered. It may be submitted by email, mail, or fax:

Helms Medical Institute
2520 Milvia Street
Berkeley, CA 94704
Fax: 510-649-8692
Email: mafp@hmieducation.com

The fields indicated with an asterisk (*) are required.

Select the session(s) you wish to attend:*
Tuition is $2000 per session OR $5500 if payment for all three sessions is received by 12 November 2019.

Introductory weekend (12-16 December 2019)Clinical One (14-18 February 2020)Clinical Two (20-24 May 2020)

First Name*

Initial

Preferred Name

Last Name*

Degree*

State Medical License Number*

Specialty*

Contact Information

Primary Email*

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Primary Phone*

Please use the format 555-555-5555 for US phone numbers.

Secondary Phone

Please use the format 555-555-5555 for US phone numbers.

Year you completed the basic HMI course:

Indicate method of payment:*

CheckPreferred - Payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704Credit Card - by phoneCall 510-649-8488 between 9:00 AM and 2:00 PM Pacific Time or fax to 510-649-8692

All training activities will take place at the Tempe Mission Palms Hotel & Conference Center, Tempe, AZ. You are requested to lodge at the hotel where a group rate has been arranged. A conference day use fee of $75 per day is required of participants who choose to stay elsewhere or who choose to share a room with another course participant.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com.