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Australian Association of Functional Rehabilitation Membership Application
Membership Information
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First Name *
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Last Name *
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DOB *
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Address *
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City *
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State *
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ZIP *
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Office Phone *
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Home Phone *
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Fax
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Email *
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Highest Degree *
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Primary Specialty Area *
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How did you hear about AAFR?
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Membership Categories (check only one box)
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Apply for Credential and Certification *
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List two professional references:
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I certify that the information I have provided to Australian Association of Functional Rehabilitation (AAFR) is true, correct, and complete. I am not providing misleading, false, or deceptive information, the association will pursue aggressive legal action. I may be asked to provide if I misrepresent my credentials, refuse to provide documentation at a later time if asked, or allow my membership with AAFR to lapse, I understand and agree that my membership and/or certification status will be revoked and my membership terminated. If the documentation required for the credential or membership status for which I am applying is not received within 6 months from the date of application, I understand that no refund will be issued in the event of the cancelation or denial of my application. I agree that I will notify AAFR in writing of any civil, criminal, or complaint that is made against me. I agree to hold harmless and indemnity AAFR and its officers, directors, employees, and agents for any misrepresentation of my credentials and for all claims, loss, judgment, or expense. AAFR does not endorse, guarantee, or warrant the work or opinions of any individual members. Membership does not imply licensing or registration by the organization of a member’s qualifications, abilities, or expertise. The objective of AAFR’s publications and the activities that it sponsors are for informative and educational purposes. The Views expressed by the authors, publishers, or presenters are their own views and do not necessarily reflect those of AAFR. AAFR does not assume any responsibility or liability for its members or subscribers’ efforts to apply or use the information, suggestions, or recommendations made by the organization, publication resources, or activities.
Have you ever been convicted of a felony? *
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Have you ever been disciplined, or are you currently under investigation, by a legal or licensing board? *
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By signing below, I agree to the terms stated above:
Print your name as you would like it to appear on your certificate (including designations). Designations must have documentation on file before they will be listed.
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Date: *
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