REGISTRATION FOR MEMBERSHIP IN PTAN(tm)

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         To register for membership in PTAN®, please provide us with
                           the following information: 
 
 
                      Name:   ________________________________ 
 
        Type of Degree - BA:  _____
                         MA:  _____ 
                         MS:  _____ 
                        MSW:  _____ 
                        PhD:  _____ 
                         MD:  _____ 
     Other (please specify):  ________________________________ 
 
            Your Profession:  ________________________________ 
 
       License(s) Number(s):  ________________________________ 
                   State(s):  ________________________________ 
 
                  Address 1:  ________________________________ 
                  Address 2:  ________________________________ 
                       City:  ________________________________ 
                      State:  ________________________________ 
                        ZIP:  ________________________________ 
                    Country:  ________________________________ 
 
                  Area Code:  ________________________________
                  Telephone:  ________________________________ 
                        FAX:  ________________________________ 
                     E-mail:  ________________________________ 
 
 
   ALONG WITH THE ABOVE INFORMATION, PLEASE ALSO INCLUDE THE FOLLOWING: 
 
            1. complete resume of your education and experience; 
 
            2. brief summary of your professional skills and area(s) 
               of specialty and expertise; 
 
            3. number of years in involvement in professional work 
               related to trauma related disorders and/or litigation 
               (please specify other related areas). 
 
   THE ABOVE INFORMATION MAY BE SENT TO PTAN VIA: 
 
               E-MAIL:  ptan@ptan.com 

                  FAX:  (619) 486-9746, (619) 486-9760, or by

         REGULAR MAIL:  PAIN AND TRAUMA ASSESSMENT NETWORK™
                        Attention: Dr. Robert Christopher
                        P.O. Box 578
                        Poway, California 92074-0578
                        U.S.A.