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Public Information Intake (Find A Naprapath) Form
Public Information Intake (Find A Naprapath) Form
This form is for public inquiries regarding Naprapathic Doctors in their cities, states and territories. The American Naprapathic Association aims for mass expansion for Naprapathic Medicine, however we need YOU in this effort! We appreciate you taking the time to give us some information about where you are located and the public service representatives that may assist us in efforts to provide access to naprapathic care to their constituent... to YOU!
Please enable JavaScript in your browser to complete this form.
Are You Subscribed to the ANA e-Newsletter Digest of Naprapathy (The DN)?
*
Yes
No
Your Information
Name
*
First
Middle
Last
Please provide your personal Email Address
***We will not share or disclose this information (for ANA internal use only)***
Would you like to be added to our email list?
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Yes
No
I am already subscribed
Any U.S. Military Service?
*
Yes
No
***Used for Statistic and Demographic Information only***
If Military Service and Branch of Service Indicated, please select one of the following:
*
Active Duty
Veteran
N/A
Mailing Address
Address Line 1
City
State / Province / Region
Postal Code
***We will not share or disclose this information (for ANA internal use only)*** It can also be used to determine your elected officials based on where you live.
Your US Representatives
These are your representatives serving in the US Congress. Congress = House of Representatives + Senate
Please provide the name of your US Senators 1
There are typically 2 for each state. They represent where you live in the United States Senate.
Please provide the name of your US Senator 2
There are typically 2 for each state. They represent where you live in the United States Senate.
Please provide the name of your US Congressman or Congresswoman
This individual represents where you live in the United States House of Representatives.
Your State Representatives
These are your representatives serving in your state legislation. State Assembly = House of Representatives + Senate
Please provide the name of your State Governor
Please provide the name of your State Representative
Please provide the name of your State Senator
Your State County Representatives
These are your representatives serving in a county in your state.
What County do you live in?
Please provide the name of your State County Board President or Executive
Please provide the name of the County Legislative Board Chair in your State County
Municipal Representatives
Please provide the name of your City or Township Mayor
Please provide the name of your City Alderman or Township Trustee
We appreciate you taking the time to give us some information about where you are located and the public service representatives that may assist us in efforts to provide access to naprapathic care to their constituent... to YOU!
Thank You for completing the ANA Public Information Intake
Please be sure to submit your form.
Submit My Intake Form