American Association of Nutritional Consultants

The following is the on-line Application for Membership and/or CNC Certification with the A.A.N.C.

By completing and electronically "signing" this application you accept, understand and agree with those terms and conditions established by The American Association of Nutritional Consultants.

You understand that you will be entitled to materials and membership services.

Required fields on the application are marked with a red asterisk (*).

Renewing A Current Membership? Click Here!
First Name*
Middle Name
Last Name*
Address*
City*
State*
Postal Code*

E-mail Address*
Day Phone
Evening Phone
Fax

Date of Birth

High School
College / Trade School
Degree(s) / Diploma(s) Received
Post-Graduate Studies
Vocational or Professional Background
Present Occupation
Employment Status

1. Have any of the following ever been revoked, suspended, refused, denied renewal, placed on probation, cancelled or voluntarily surrendered by you or any of your employees?
State License or Certification	....... Yes ............. No
Malpractice Insurance	....... Yes ............. No
If "Yes," explain here; please include dates, allegations and amounts.

2. Has any claim or suit ever been brought against you or any of your employees, or are you aware of any incident that might reasonably lead to a claim or suit?
Yes ............. No
If "Yes", explain here; please include dates, allegations and amounts.

What languages do you speak fluently?
How long have you been involved professionally in the field of nutrition?

To what other health-oriented associations do you belong? (Please spell out full name of organizations. No acronyms, please. List no more than three.)
1. 2. 3.
As references, please provide the names and addresses of THREE nutrition oriented health care professionals with whom you are professionally acquainted.
1. 2. 3.

Types of Membership* (click here to learn more)
Association Membership		$60 Annually
	Membership Only
	Self-employed Full-time (20 or more hours/week)	$283 Premium
	Self-employed Part-time (less than 20 hours/week)	$132 Premium
Professional Membership		$60 Annually
	Membership Only
	Self-employed Full-time (20 or more hours/week)	$283 Premium
	Self-employed Part-time (less than 20 hours/week)	$132 Premium
	Insurance for additional employee(s)	$76 Premium each
Diplomate Membership		$60 Annually
	Membership Only
	Self-employed Full-time (20 or more hours/week)	$283 Premium
	Self-employed Part-time (less than 20 hours/week)	$132 Premium
Corporate Membership		$500 Annually
	Standard Corporate Membership
	I am not applying for a membership at this time.

	Please charge my credit card for my membership dues for the amount of $ .
	I would like to make a donation of $ to the Health Freedom Fund.
Please enter your name as you would like it to appear on your certificate:

Do not check the following boxes unless you are applying for C.N.C.® Certification.
	I understand that a one time fee of $250 is required with my application for C.N.C.® Certification.
	I understand that certification is only available to Professional Members of the A.A.N.C. (My membership expires on: .)
	I understand that upon successful completion of the certification examinations, I will be issued a second certificate in addition to my membership certificate designating me as a Certified Nutritional Consultant (C.N.C. ®) and authorizing me to use the initials C.N.C.® after my name.
	I understand and agree that neither this application nor the payment of the examination fees in any way guarantees that I will be certified and that such certification will be issued only upon successful complettion of the examinations.
	I understand that I will be refunded $100.00 of the examination fee should I fail to complete the examination successfully after three attempts. There will be a 30 day mandatory waiting period between the first and second attempt and a 60 day waiting period between the second and third attempts.

Agreement
	By completing this application, I accept, understand and agree with those terms and conditions established by The American Association of Nutritional Consultants. I understand I will be entitled to materials and membership services. I am verifying that all information provided is accurate and complete. I understand that if for some reason my application for insurance is rejected, I will be charged only $60.00 for my membership.
	I understand that no coverage shall be considered in effect until this application has been approved by V. I. Insurance Brokers and that the applicable fully earned annual premium has been irrevocably credited to the trustee bank account of said broker. Only upon receipt of a Certificate of Insurance from the Master Policy issued to the AANC Risk Purchasing Group will coverage be afforded me.
	I hereby declare that the above statements, attachments to this application and particulars are true to the best of my knowledge, and that I have not withheld or misrepresented any material facts related to this application for Professional Liability Insurance. I agree that this application and any attachments shall be the basis of the contract with the Insuring Company.

Form of Payment
	Check/Money Order (please mail your completed form with your check/money order)
	Credit Card:

Name as it appears on card:
Credit Card Number
Expiration Date
Card Verification Number (help)
Today's Date

How did you hear about AANC?
Please be aware that this completed form will also be mailed to you for your signature.

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