Auricular Detoxification Specialist Info (Ads) Maryland (Page 2 of 3) in pdf

Auricular Detoxification Specialist Info (Ads) Maryland Page 2

TRAINING:

NOTE: Auricular Detoxification Specialist Registrants must attach documentation of successful completion of a

training program in acupuncture for the treatment of alcoholism, substance abuse or chemical dependency that

consists of a minimum 70 hour basic training of which 40 hours are clinical training.

Name of School: ______________________________________________________

Address: ____________________________________________________________

Dates of Attendance: ___________________________________________________

SUPERVISOR INFORMATION:

1. Name of Supervising Acupuncturist:________________________________________

2. Supervisor’s Maryland License Number:____________________________________

3. Supervisor’s Telephone Number:__________________________________________

4. Supervisor’s Email Addresss: ____________________________________________

5. Supervisor’s Signature:__________________________________________________

************************************************************************

RELEASE OF INFORMATION

**(

Must be signed in the presence of a Notary Public)**

I hereby grant a release to the State of Maryland Board of Acupuncture to secure any information or

document(s) needed to evaluate my application for certification.

(ADS Applicant Signature)

(Date)

PASTE PICURE HERE

CURRENT PASSPORT PHOTO OF APPLICANT

**(

Must be signed in the presence of a Notary Public)**

Year Picture Taken

I attest that this photograph is a genuine likeness taken in the year

________________________________

indicated.

(applicant’s signature)

NOTARY PUBLIC

Sworn before me this

Day of

, 20

______________________________

(Notary - Name Printed)

(Notary - Signature)

NOTARY SEAL

My Commission Expires

01/13

Auricular Detoxification Specialist Info (Ads) Maryland Page 2