Ambassador Administration

Your Name:
Practice, Hospital or Organization Name:
Address:	Street Address Suite Number
	City State Zip
Practice Phone:
Practice Fax:
Practice Website:
Office Email Address: (Used to send newsletters and update)
Name of Office Manager or Administrative Contact
Title of Office Manager or Administrative Contact
Phone of Office Manager or Administrative Contact
Email Address of Office Manager or Administrative Contact
Personal Email Address: (Used to log in to the Pain Care Provider Directory administration pages)	Your personal email address will not be published in the directory.
Password for the Ambassador Directory: (Used to log in to the directory administration pages)	Your password will not be published in the directory..
We can include your listing in the Pain Care Provider Directory only, the Pain Ambassador Listing only, or both. Please indicate your preference here.	Both Pain Care Provider Directory Only Pain Ambassador Only None; deactivate my listing

Medical Specialty and Board Certifications: (check all that apply)