Join MSBMB!

If you would like to become a NEW member of the MSBMB Biofeedback Society follow the steps below.

Step 1

Fill out the form below.

Step 2

Pay your annual membership dues (You will be directed to a page where you can pay your dues after submitting the form).

Step 3

Take advantage of the member benefits!

• Public Directory Listing for attracting patients and networking with other practitioners. Make your listing effective
• Conference Discounts
• Discounts for articles published to the blog – details coming soon!

Membership Application

Required fields in blue
Username*
Password*
Password (again)*
Membership Type*	Full MemberStudent/AffiliateCorporate
General Information: Please Note: The information in this section (and only this section) will appear on our member directory. If you would like to show something in your listing make sure to check the appropriate checkbox.
First Name*
Last Name*
Degrees / Credentials (Spelled out)
Business Name*
Show Business Name in Profile
Business Address*
Show Business Address in Profile
Work Phone*
Show Work Phone Number in Profile
Cell Phone
Show Cell Phone Number in Profile
Fax
Show Fax Number in Profile
Email*
Show Email Address in Profile
For website listing please leave OFF the http:// (for example www.example.com)
Website
Description you want displayed as part of your member listing: (Example: Specialties, services offered, modalities, etc. Please limit to 250 words or fewer.)
Description
Personal Information: Please Note: This information will not be published on the MSBMB website.
Mailing Address (If different from above)*
Home Phone*
Home Email*
Comments / Questions
Note: By submitting the above information, you agree to the following: 1. I affirm that the statements made in this application correctly represent my qualifications for election.
2. In making this application, I agree to and will support the objectives of the Michigan Society of Behavioral Medicine and Biofeedback (MSBMB) as set forth in the Ethical Standards adopted by the Society.
3. I also agree to allow MSBMB to post the information not designated as private that I entered above.
I agree with the above statements*

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