Membership Application

Membership

	Student/Associate Membership (no directory listing)	$50
	Individual Membership	$150

	Program Membership or Group Practice (company name and up to 3 individual members)	$250

Section 1: Business Information


Contact Information
Business Name (if applicable):

Main Contact: First Name*:		Last Name*:

Title (MD, RD):

Business Address*:

City*:

State/Province*:

Zip Code*:

Country*:

Phone*:

Alt. Phone:		Do not post this information in the public directory

E-mail Address*:		Do not post this information in the public directory

Website URL:		Do not post this information in the public directory


Listing Location

Country*:

State*:

State/Province*:

Specialties

Please indicate which discipline categories you would like your listing tagged with (choose all that apply)

Physicians (endocrinology, obgyn, infertility, dermatology)

Psychology (psychiatry, psychotherapy, addictions)

Nutritional Counseling

Alternative/Holistic Medicine

Other (hair removal, life coach, physical fitness/trainer)

Write a paragraph about your practice/facility to personalize your listing. Describe your treatment setting and approach. Include specialties, experience, support groups and services offered. Limit 80 words.

We offer a Support Group

Support Group Name:

Contact Information:

Section 1.1: Additional Members

Member 1: Main Contact

First Name:		Last Name:

Title (MD, RD):

Phone:		E-mail Address:

Member 2: Members must complete all areas of Section 2 and 3 to be listed in the directory.

First Name:		Last Name:

Title (MD, RD):

Phone:		E-mail Address:
Section 3 Section 2

Member 3: Members must complete all areas of Section 2 and 3 to be listed in the directory.

First Name:		Last Name:

Title (MD, RD):

Phone:		E-mail Address:
Section 3 Section 2

Member 2 - Section 1.1.2:

Degrees:

Years Experience Post Degree:

License Types** Please include numbers and issuing agency.

**If you are not licensed or registered, it will be noted in your profile.

Student/Associate Members, please include a valid trainee, pre-license, or intern certificate for verification.

Certifications:

Metropolitan area you serve:

Associations you belong to:

Number of PCOS patients you treat per year:

Section 1.1

Member 3 - Section 1.1.2:

Degrees:

Years Experience Post Degree:

License Types** Please include numbers and issuing agency.

**If you are not licensed or registered, it will be noted in your profile.

Student/Associate Members, please include a valid trainee, pre-license, or intern certificate for verification.

Certifications:

Metropolitan area you serve:

Associations you belong to:

Number of PCOS patients you treat per year:

Section 1.1

Member 2 - Section 1.1.3: Additional Networking Information

This information will be posted in the directory

Remember, to be part of a successful and rewarding networking team we need speakers, listeners, entrepreneurs, and active, innovative minds. We have been successful in creating PCOS awareness and now we must meet this with an abundance of competent, energetic and ethical practitioners.

Check if:

you would like to be placed on the ‘available for mentoring’ list.

you are interested in joining a chapter network group.

OK to post contact info on network Professional Members Listing in your area (members only section).

you are interested in hosting a single network chapter event.

you are interested in hosting a monthly network event.

you would like to be placed on the Speakers Bureau Listing.

you would like to submit an article.

Which three specific topics would you like to learn more about?

Additional Comments:

Terms and Conditions:

PCOS Network Membership Agreement

PCOS Network membership is limited to individuals 18 years of age or older.  PCOS Network membership is a fee-based service that allows you to post information about your profession or practice in the PCOS Network Directory.  Membership also includes 24-hour access to the members-only section of the website.  The term of membership is 12 months beginning the date of acceptance.  Student/Associate Membership includes 24-hour access to the members-only section but does not provide inclusion in the Directory.

PCOS Network members have read and agree with the general Terms & Conditions which are posted at the bottom of the website in addition to the policies posted herein.  Members agree to notify PCOS Network via email if anything on the original membership application changes.

You may cancel your membership at any time however membership fees are non-refundable.  If you wish to have your directory listing omitted, you must notify PCOS Network via e-mail and the listing will be deleted within 30 days.  PCOS Network may, at its sole discretion, terminate your password and membership account in whole or in part and remove, alter or discard any content within the Site at any time and for any reason.  The actions may be effective without prior notice to you.

Members agree that PCOS Network may use applicant’s registration information in aggregate (collective) form for marketing or other promotional purposes.

PCOS Network membership is provided on an “AS IS” and “AS AVAILABLE” basis without warranties of any kind.  Memberships may not be assigned or transferred.

As part of the registration process, you will be provided a username and password.  You are entirely responsible for any and all activities that are conducted through your account.  You agree to notify PCOS Network immediately of any unauthorized use of your account or any other breach of privacy.

PCOS Network makes no representation or warranty that the content and materials on the website are appropriate or available for use in locations outside the United States.  Those who choose to access and become members from other locations do so on their own initiative and at their own risk, and are responsible for compliance with local laws.

PCOS Network may amend this agreement at any time by providing e-mail notification.

I have read and agree to the above terms for Membership and have read and agree to the general PCOS Network Terms & Conditions.

I have read and agree to the terms and conditions.

Section 1.1

Member 3 - Section 1.1.3: Additional Networking Information

This information will be posted in the directory

Check if:

you would like to be placed on the ‘available for mentoring’ list.

you are interested in joining a chapter network group.

OK to post contact info on network Professional Members Listing in your area (members only section).

you are interested in hosting a single network chapter event.

you are interested in hosting a monthly network event.

you would like to be placed on the Speakers Bureau Listing.

you would like to submit an article.

Which three specific topics would you like to learn more about?

Additional Comments:

Terms and Conditions:

PCOS Network Membership Agreement

PCOS Network membership is limited to individuals 18 years of age or older.  PCOS Network membership is a fee-based service that allows you to post information about your profession or practice in the PCOS Network Directory.  Membership also includes 24-hour access to the members-only section of the website.  The term of membership is 12 months beginning the date of acceptance.  Student/Associate Membership includes 24-hour access to the members-only section but does not provide inclusion in the Directory.

PCOS Network members have read and agree with the general Terms & Conditions which are posted at the bottom of the website in addition to the policies posted herein.  Members agree to notify PCOS Network via email if anything on the original membership application changes.

You may cancel your membership at any time however membership fees are non-refundable.  If you wish to have your directory listing omitted, you must notify PCOS Network via e-mail and the listing will be deleted within 30 days.  PCOS Network may, at its sole discretion, terminate your password and membership account in whole or in part and remove, alter or discard any content within the Site at any time and for any reason.  The actions may be effective without prior notice to you.

Members agree that PCOS Network may use applicant’s registration information in aggregate (collective) form for marketing or other promotional purposes.

PCOS Network membership is provided on an “AS IS” and “AS AVAILABLE” basis without warranties of any kind.  Memberships may not be assigned or transferred.

As part of the registration process, you will be provided a username and password.  You are entirely responsible for any and all activities that are conducted through your account.  You agree to notify PCOS Network immediately of any unauthorized use of your account or any other breach of privacy.

PCOS Network makes no representation or warranty that the content and materials on the website are appropriate or available for use in locations outside the United States.  Those who choose to access and become members from other locations do so on their own initiative and at their own risk, and are responsible for compliance with local laws.

PCOS Network may amend this agreement at any time by providing e-mail notification.

I have read and agree to the above terms for Membership and have read and agree to the general PCOS Network Terms & Conditions.

I have read and agree to the terms and conditions.

Section 1.1

Section 2:

Degrees:

Years Experience Post Degree:

License Types Please include numbers and issuing agency.

Student/Associate Members: Please include a valid trainee, pre-license, or intern certificate for verification.

Certifications:

Metropolitan area you serve:

Associations you belong to:

Number of PCOS patients you treat per year:

Section 3: Additional Networking Information

Check if:

place me on the available to be a mentor list

you are interested in joining a chapter network group.

OK to post contact info on network Professional Members Listing in your area (members only section).

you are interested in hosting a single network chapter event.

you are interested in hosting a monthly network event.

you would like to be placed on the Speakers Bureau Listing.

you would like to submit an article.

How did you hear about us? Be as specific as possible.*

Which three specific topics would you like to learn more about?

Additional Comments:

Terms and Conditions:

PCOS Network Membership Agreement

PCOS Network membership is limited to individuals 18 years of age or older.  PCOS Network membership is a fee-based service that allows you to post information about your profession or practice in the PCOS Network Directory.  Membership also includes 24-hour access to the members-only section of the website.  The term of membership is 12 months beginning the date of acceptance.  Student/Associate Membership includes 24-hour access to the members-only section but does not provide inclusion in the Directory.

PCOS Network members have read and agree with the general Terms & Conditions which are posted at the bottom of the website in addition to the policies posted herein.  Members agree to notify PCOS Network via email if anything on the original membership application changes.

You may cancel your membership at any time however membership fees are non-refundable.  If you wish to have your directory listing omitted, you must notify PCOS Network via e-mail and the listing will be deleted within 30 days.  PCOS Network may, at its sole discretion, terminate your password and membership account in whole or in part and remove, alter or discard any content within the Site at any time and for any reason.  The actions may be effective without prior notice to you.

Members agree that PCOS Network may use applicant’s registration information in aggregate (collective) form for marketing or other promotional purposes.

PCOS Network membership is provided on an “AS IS” and “AS AVAILABLE” basis without warranties of any kind.  Memberships may not be assigned or transferred.

As part of the registration process, you will be provided a username and password.  You are entirely responsible for any and all activities that are conducted through your account.  You agree to notify PCOS Network immediately of any unauthorized use of your account or any other breach of privacy.

PCOS Network makes no representation or warranty that the content and materials on the website are appropriate or available for use in locations outside the United States.  Those who choose to access and become members from other locations do so on their own initiative and at their own risk, and are responsible for compliance with local laws.

PCOS Network may amend this agreement at any time by providing e-mail notification.

I have read and agree to the above terms for Membership and have read and agree to the general PCOS Network Terms & Conditions.

I have read and agree to the terms and conditions.

Section 4: Payment

Your application will take several days to process.

Payment Method:	Online Shopping Cart*	Check/Money Order**	PayPal*

Discount Code:

Payment by Check/Money Order:

** Payable to: PCOS Network

* Credit card payments outside the U.S. will be processed at the current exchange rate on the date of the transaction.

Mail application and check/money order to:

Membership

PCOS Network

P.O. Box 2242

Manhattan Beach, CA 90267

Section 5: User Credentials

Please choose a username and password for your account.

Username*:

Password*:

Confirm Password*:

Payment via PayPal:

Click Next to make your payment via PayPal. After your payment is complete, you will be returned to pcosnetwork.com to proceed to member login.

Payment via Online Shopping Cart:

Click Next to make your payment via our online shopping cart. After your payment is complete, you will be returned to PCOSNetwork.com to proceed to member login.

Payment via PayPal:

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Payment via PayPal:

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Payment via Check/Money Order:

Your application has been submitted for approval and payment confirmation.

Payment by Check/Money Order:

** Payable to: PCOS Network

Mail check/money order to:

Membership

PCOS Network

P.O. Box 2242

Manhattan Beach, CA 90267

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Membership Application Submitted

Thank you, your membership application has been submitted for approval.

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Your payment has been received and changes to your membership application have been submitted for approval.

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DISCLAIMER: This Site does not offer medical or psychological advice, diagnosis or treatment, and the contents are for informational purposes only. PCOS Network and its affiliates do not guarantee the accuracy, completeness, most current, reliability, or adequacy of any resources, information, product, or process available at or from this Site. The views and opinions expressed in this Site are strictly those of the authors and are presented without editing. The opinions expressed therein do not necessarily reflect the position of PCOS Network.READ FULL TERMS & CONDITIONS