User Profile

*First Name:

*Last Name:

*Username:

'Username', once assigned by the system or by the User, is permanent and cannot be changed, nor are duplicate usernames allowed in the system

*Display Name:

*Degree:

For membership or core curriculum registrations, select only your primary designation from those eligible included in this list i.e. MD, PT, DDS/DMD, DC, ND, Bac RN, LAc/RAC

Speciality:

Business Name:

*Street Name, Apt or Suite #, etc:

*City:

*Postal Code/Zip (letters in uppercase; ensure accuracy) :

For countries, other than Canada and the U.S., where address fields such as postal code/zip or province/state may not apply, enter the default N/A

*Country:

*Province/State:

Bus Ph:

Contact Number included in Practitioner Search and Member Directory

Fax #:

*Home Ph:

Contact number or cell number required

*Email Address:

*Licence #:

Licence # and Expiry Date defaults: These are mandatory fields. For Final Year Students not yet licensed or those registering for a Special Event not limited to AFCI eligible practitioners (see Membership), please enter XXXX in the Licence # field and select February 1, 2008 to fill in the Licence Expiry Date field below.

*Licence Expiry Date:

Select Date

*Licence Issued in Country:

*Licence Issued in Province/State/Region:

AFCI values your privacy – Member Directory and Practitioner Search

I consent to have my contact information displayed in the Member Directory and Practitioner Search, if eligible, or any other AFCI Listing. Business contact information will be displayed on the Member Directory and Practitioner Search, if eligible. Email addresses will not be displayed on the Practitioner Search. Please de-select the box to display your information.

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AFCI values your privacy – Information to Regulators and Insurers

AFCI will provide your current membership and certification information to regulators or insurers on request. If you do NOT consent to the release of this information then select the box to Keep Info Private.

Keep Info Private

I agree to abide by the Policies of AFCI.

I Agree

I certify that the information given in this application is true and correct. I understand that a false or misleading statement may result in cancellation of registration and credit earned toward CAFCI designation.

I Certify

First Time Registrants for New Membership or Core Curriculum: As part of AFCI's approval process, you will be required to send a copy of your current licence or letter from your academic institution as proof of your student status to accompany your registration. If paying online, a pre-authorized payment will automatically be set up as part of the approval process. Once approved. AFCI will complete the payment process.

Check here to receive AFCI Notifications by email. Leave blank to be sent by Canada Post.

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*Password:

Password must be a minimun of 7 characters. Remember your User Id and Password.

*Confirm Password:

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Account Setup