| If you have met the requirements for this list by attending the EXT class and 2 spine classes, (you can substitute the full spine class for one of the 2 regular spine classes), then please fill out the information below and mail this form and your check to MPI. | |
| Name: | _________________________________________ |
| Email: | _________________________________________ |
| Office Address: | _________________________________________ |
| Office Address 2: | _________________________________________ |
| City: | _________________________________________ |
| State: | _________________________________________ |
| Country: | _________________________________________ |
| Zip Code: | _________________________________________ |
| Office Phone: | _________________________________________ |
| Office Fax: | _________________________________________ |
| Office Website: | _________________________________________ |
| Chiropractic College: | _________________________________________ |
| Year Graduated: | _________________________________________ |
| Year MPI Certified: | _________________________________________ |
| MPI Classes taken: | _________________________________________ |
| _________________________________________ | |
| _________________________________________ | |
Please fill out this form and mail to: Motion Palpation Institute 3197 Linwood Ave Cincinnati, OH 45208 Make your check or money order payable to: Motion Palpation Institute
Prices: | |