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AQTN, a non-profit association Membership application form Page 1 of 3 www.AQTN.ca | [email protected] You are applying for a membership as a: [ ] Naturopath (ND) [ ] Naturotherapist (nd) Have you ever been, or are you currently a member of any other association or regulatory body? [ ] Yes [ ] No If yes, please specify which one(s): If yes, were you ever sanctioned? [ ] Yes [ ] No Your preferred correspondence language: [ ] French [ ] English Optional: Quebec Enterprise number (NEQ) Does law 21 (on psychotherapy) have any relevance to your practice? [ ] Yes [ ] No [ ] I don’t know Note: Your application must be accepted prior to applying for liability insurance. The required form will be included in your welcoming kit. Personal information [ ] Ms. [ ] Mr. Full name: Date of birth (YYYY-MM-DD): Language(s) spoken: Primary business telephone number: Other telephone number: Email (use block letters): Website: Professional Website or Facebook: Would you like for us to place an order for you to receive a free SQUARE and account? The device plugs into your cell phone, allowing you to process credit card and debit card payments. Note: You must pay by cheque. [ ] Yes [ ] No AQTN Association québécoise des thérapeutes naturels AQTN, CP 28551, CSP Verdun QC H4G 3L7

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  • AQTN, a non-profit association Membership application form

    Page 1 of 3

    www.AQTN.ca | [email protected]

    You are applying for a membership as a:

    [ ] Naturopath (ND) [ ] Naturotherapist (nd)

    Have you ever been, or are you currently a member of any other association or regulatory body?

    [ ] Yes [ ] No

    If yes, please specify which one(s):

    If yes, were you ever sanctioned? [ ] Yes [ ] No

    Your preferred correspondence language:

    [ ] French [ ] English

    Optional: Quebec Enterprise number (NEQ)

    Does law 21 (on psychotherapy) have any relevance to your practice?

    [ ] Yes [ ] No [ ] I don’t know

    Note: Your application must be accepted prior to applying for liability insurance. The required form will be included in your welcoming kit.

    Personal information

    [ ] Ms. [ ] Mr.

    Full name:

    Date of birth (YYYY-MM-DD):

    Language(s) spoken:

    Primary business telephone number:

    Other telephone number:

    Email (use block letters):

    Website:

    Professional Website or Facebook:

    Would you like for us to place an order for you to receive a free SQUARE and account? The device plugs into your cell phone, allowing you to process credit card and debit card payments.

    Note: You must pay by cheque. [ ] Yes [ ] No

    AQTN Association québécoise des thérapeutes naturels AQTN, CP 28551, CSP Verdun QC H4G 3L7

  • Association québécoise des thérapeutes naturels

    Membership application form

    Page 2 of 3

    www.AQTN.ca | [email protected]

    Correspondance address:

    Work address (if different):

    What is your estimated frequency of treatments:

    _______ Treatments per [ ] week [ ] month

    Important information:

    Membership fees cover one year.

    We communicate news and information by email.

    Renewal notices are sent one month in advance.

    If your application is refused, any fees paid will bereversed or cancelled. Accepted applications arenon-refundable.

    First year membership fee: $ 160.00

    Includes a welcoming kit, access to our services, Intranet and 50 receipts to start. Free receipts available at all times, details on our website. There are no taxes.

    Accepted payment methods:

    Online with Paypal, we will email you a link.

    Interac e-transfer, send your payment to: « [email protected] ». Use an evident security code or email it to us.

    PROVIDE ONE REFERENCE REFERRAL INCENTIVE In a few words: What motivated you to decide to

    become a therapist? Another therapist, a teacher or an employer. Do not use family members.

    Please include: Name, Relationship and Telephone Number.

    Referred by another AQTN therapist? Write their permit number below so they can benefit from two free months of membership.

    If paying by credit card:

    ________ - ________ - ________ - ________

    Exp. date: _________ Verification # (CVV): _________

    Shall we keep this information for other authorised purchases, such as additional receipt orders?

    [ ] Yes [ ] No

    Credit card (above).

    Cheque payable to « AQTN ».

    Name:___________________

    Permit # : _______________

    AQTN Association québécoise des thérapeutes naturels AQTN, CP 28551, CSP Verdun QC H4G 3L7

  • Association québécoise des thérapeutes naturels

    Membership application form

    Page 3 of 3

    www.AQTN.ca | [email protected]

    Please sign in the white area of the box below. It will only be available to insurance companies to allow them to better process claims and to reduce potential fraud. It also authorizes AQTN to contact your school(s) in order to verify your training, whether private or public schools.

    By signing below, you agree to abide by AQTN’s Code of ethics at all times throughout your practice, you certify being 18 years or older and that you are permitted to work legally in Quebec.

    Signature (you can also print the form and sign in ink):

    All information provided is accurate and complete.

    Date: ________________________

    AQTN values your privacy. You may review our Privacy policy to know what information we collect, why it is collected, and how we use it.

    Checklist of required documents

    This duly completed application form.

    Copies of all relevant diplomas / attestations including the hours for each.

    Two pieces of photo ID, such as a health care card and a driver’s license.

    A brief description of your personal therapeutic approach. No more than one page.

    Optional: CV, Business card, a photo for our registry.

    Submit your application by:

    Faxing everything to 514-317-4602.

    Email with scanned attachments to « [email protected] ».

    Regular mail via Canada Post.

    Thank you for choosing AQTN Please allow us up to 15 days to process your application.

    AQTN Association québécoise des thérapeutes naturels AQTN, CP 28551, CSP Verdun QC H4G 3L7

    AQTN CP 28551

    CSP Verdun QC H4G-3L7

    Check Box1: YesCheck Box2: OffSalutation: OffRegulatory body: OffFull Name: Text1: DOB: Sanctioned: OffLanguage: Prefer Language: OffTelephone1: Telephone2: Email: Text2: Square: OffSAVE1: PRINT1: Website: Facebook: Treatment: OffPractice: OffTreatments: Address: Credit card1: Credit card2: Credit card3: Credit card4: Expdate: Verification CVV: Work_Address: Reference: Few Words: SAVE2: PRINT2: Date: App_Form: OffDiploma: OffBusiness Card: OffSAVE: PRINT: Photo ID: OffTherapeutic: OffAdditional Receipt: OffName: Permit: Payment Method: Off


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