Membership Application for the Association of Professional Trichologists

First Name *

Last Name *

Professional Title *

Email *

Phone Number (will be ONLY used to receive reminders, confirmations and notifications)

Do you want to receive text messages about meeting reminders, appointment confirmations, and notifications? *

Yes, I want to receive text messages for meeting reminders, appointment confirmations, and notifications.

No, I DO NOT want to receive text messages for meeting reminders, appointment confirmations, and notifications

Check below if the phone number you provided is your number on WhatsApp.

Yes, this is my WhatsApp number

Address

Street Address *

City

State

Country

Postal code

Website *

Instagram

What educational experience do you consider to be the highest you've received?

What is your Profession?

How many hours of education have you completed in TRICHOLOGY? (Combine the collective number of hours from different programs - if applicable.) *

Upload documentation to support your professional education and training or student status. (i.e. licenses, certifications, diplomas, school transcript, valid student identification, etc.) Total file size can not exceed 25MB and must be no more than 5 files total. Allowable upload files include JPG, PNG and PDF ONLY. **NOTE: If you do not upload your document(s) during the application process, they MUST be sent to [email protected] within 2 days of application completion. Otherwise, your application will be void.

Read the APT Code of Conduct

Acknowledgement
By signing, the individual named above understands the Code of Conduct at events, meetings and on-line forums affiliated with, or in reference to, the Association of Professional Trichologists.

The signee agrees to conduct themselves in a manner consistent with this policy for the duration of their relationship with the Association of Professional Trichologists. *

Yes, I agree.

Signature *

Clear

Signed Date *

Choose Your Preferred Method of Payment for the membership fee

Credit Card

PayPal

Note: Recurring and Payment Plan Options are ONLY Available via Credit Card.

Thank you for completing this form. Upon submitting, you will be sent to the payment page.

INFO:
Click it and forget it! Choose to have recurring payments on the payment page otherwise, you'll need to manually renew your membership every year.