Member Application Registration Form

(as you would like it to appear in the directory)
Email Address*
Phone Number
Practice Website
Professional Affiliation AMA AAPB BCIA APA
Other, Please specify
Practice Speciality Areas
Professional License Number
Application Type

How would you like to be involved with BSF?
Board Participation Committee Membership
Writing for Florida Biofeedback Conference Organizing
Legislative Advocacy Teaching
Other, Please Specify

Credit card:*
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Expiration date:*
Verification code:*
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Amount authorized:* $

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