NOTE: Once you have successfully submitted your annual practice report the form will disappear and you should receive a message on the screen above that says that the form has been submitted. You will also receive an automatic emailed confirmation, though it may take a few hours to appear in your inbox (if you don't see it, please check your spam and trash folders in case it was misdirected).
If the form does not disappear after you click on the “Submit” button, please review your form to see if any fields have been left blank. The form will only be accepted if all of the fields have been filled.
If you run into technical difficulties, please contact Jen at firstname.lastname@example.org.
If you wish to inquire about your affiliation or make changes after the form has already been submitted, please contact Leslie at email@example.com.
Annual Practice Report
PART TWO (OPTIONAL)
We would like to add your photo to the public directory listing we will be creating for our alumni on our website. The intent of the new directory is to bring greater visibility to your work. If you would like us to include your photo or a logo for your business, please upload it below.
Please submit only one photo. The system is designed to accept .jpg, .png, and .gif files that are less than 256 MB. Optimally, we are looking for photos that are 96 dpi or higher and at least 500×500 pixels. If you have any questions about these settings or any difficulties uploading your image, please send it to Jen at firstname.lastname@example.org.
$100 Affiliation Fee
Please select the “Add to Cart” button below and you will be led through the online purchase process.