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1. Highest Degree (check one)

Associate	MD	DC	BA/BS	PhD
DDS	MA	MD/PhD	DO	Other

2. From what institution did you receive your highest degree?

3. Do you wish to be included on the Public Information Packet Clinical Referral List?
(To be listed as a practitioner, you must be licensed.)
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If yes, please complete all items on this page

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4. Corporate Members:
Recognizing that progress in our field will rely importantly on productive interaction between academic, clinical, governmental and industrial groups, the Society for Light Treatment and Biological Rhythms welcomes the active participation of its Corporate Members in supporting the SocietyÕs activities and presenting technology they have developed for the market. The Society, however, does not endorse or specifically recommend any particular lighting or photo-technology product for clinical, research or general-purpose use. Furthermore, the Society maintains no responsibility for implicit or explicit claims for efficacy, or instructions for use, that may be contained in literature written and distributed by its Corporate Members. The Society does not permit its name to be used in any manner, or its publications cited or quoted, in corporate advertising or other materials. Firms applying for corporate membership must acknowledge and agree to this policy by checking the box below.
I have read and agree to the preceding compliance statement

5. Check up to 5 specialty areas:

1. Addiction	21. Health Psychology	41. Pineal Function
2. Allergies	22. Hypnosis	42. PTSD
3. Anesthesiology	23. Immunology	43. PMS
4. Anxiety Disorders	24. Instrumentation	44. Psychoanalysis
5. Attention Deficit Disorder	25. Internal Medicine	45. Psychobiology
6. Behavioral Medicine	26. Jet Lag	46. Psychopharmacology
7. Biological Rhythms	27. Light	47. Psychophysiology
8. Biophysics	28. Medical Geography	48. Psychosomatic
9. Counseling	29. Melatonin	49. Psychiatry
10. Dreams	30. Menstrual Cycles	50. Psychology
11. Eating Disorders	31. Mood Disorders	51. Pulmonary Medicine
12. Emergency Medicine	32. Neurology	52. Reproduction
13. Endocrinology	33. Neuroscience	53. Seasonal Affective Disorder (SAD)
14. Engineering	34. Nursing	54. Sexual Abuse
15. Environmental Issues	35. Obesity	55. Shift Work
16. Equipment Sales	36. Ophthalmology	56. Sleep Disorder
17. Family Practice	37. Optometry	57. Stress
18. Forensic Psychiatry	38. Pain	58. Other
19. Geriatrics	39. Pediatrics
20. Health Enhancement	40. Physical Med/Rehab