Professional Certification Program Orthopedic Acupuncture
and Oriental Medicine
Registration Form
First Name
Last Name
Street Address
Zip Code
Home Phone
Cell Phone
Date of Birth
Degree and  
License Number
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about us?
Payment Information
Name on Card
Select Card Type
Card Number
Expiration Date
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              Select Payment Option (1 or 2)

   Orthopedic Acupuncture Certification

1. $ 599.00
**Best Value**One Time Payment due by 08-01-2018

2. $ 649.00 One Time Payment if after 08-01-2018
Select payment Option:
Payment Amount
Option Two

      Payment and Refund Policy

Payment via credit card (Visa, Master Card, Discover or
American Express), cash or checks are accepted. Upon
receipt of your paid tuition, an email confirmation from
Connecticut Acupuncture Certification Program will be
sent to you.

Refund Policy:
Refunds, less an administrative fee of $95.00, will be
issued for all cancellations received by September 1,
2018.  Refund requests must be submitted by US Postal
Certified Mail and must be postmarked by September 1,
2018.  No Refund will be issued should cancellation
occur after September 1, 2018.  "No shows" are subject
to the full course fee and no refunds will be issued once
the program has started.

In the event of an emergency or personal illness, credit
for the program will apply toward future programs.
Option One
Payment Options
Tuition and Payment Plan Options for

1. $ 599.00
**Best Value**One Time Payment due in
full by 08-01-2018

2. $ 649.00 One Time Payment in full if after

Registration must be complete and paid by
September 1, 2018