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Date:

  

Name:

  

Address:

  

City:

                                                        State:          Zip:             Country:

Phone:

  

Email:

  

Sex:

[   ] Male    [   ] Female                 Age:

Membership Type:

[   ] Professional $150
          Professional members fulfill at least one of the following requirements:
          Possess a license with powers to diagnose pathology and or disease.
          Possess a Ph.D. or equivalent in a health care related science.
          (Please submit copy of current license [or diploma for PhD.])

[   ] Associate $150
          Includes thermographic technicians, thermography-related businesses,
          and students majoring in a field directly related to thermography.

Please make checks or money order out to IACT and mail to:
          International Academy of Clinical Thermology
          C/O Secretary/Treasurer 
          Robert L. Kane, DC, DABCT, DIACT(B), FIACT
          950 Woodside Road #5
          Redwood City, CA. 94061
Type of Thermographic Equipment Used (If Any)

Prior Experience in Clinical Thermography (if any)

Memberships in other Thermographic Associations

What are your interests in Clinical Thermography and the IACT? (Check all that apply)

[  ] General Thermography
[  ] Breast Thermography
[  ] Paraspinal Thermography
[  ] Thermographic Technician

   

[  ] Education and Training
[  ] Certification
[  ] Professional Support and Resources
[  ] Other ________________________


Signature of Applicant:                                                             Date:                           

Membership in any category of the IACT shall not be denied or abridged because of sex, color, creed, race, religion, disability, ethnic origin, national origin, sexual orientation, age, or for any other reason unrelated to character or competence.  Nor shall membership in any category of the IACT be denied to any person who meets the requirements for membership as set forth in these Bylaws. In considering applicants for membership, information as to the character, ethics, professional status, and professional activities of the individual may be considered.