What do you receive with the CIC Program?
		A Customized Page on the ImPACT™ Web Site featuring your Clinic/Services
		A Listing on ImPACT's National Network of Doctors
		ImPACT™ Marketing Materials
		Assistance with Media/PR
		Excellent Referral Opportunities
		Authorized use of the ImPACT™ CIC Logo for your Marketing Materials and Business Cards

- Become an ImPACT™ Partner - as our clientelle grows, your clinic grows
- Standing out in a competitive marketplace
- Offering better quality of care for your patients
- Increased media coverage
- Significant revenue generating opportunities

To become a Credentialed ImPACT Consultant™ (CIC), you must have appropriate education, training, and experience with the ImPACT program. Each CIC must designate a primary contact person for their organization.

Have you previously worked for a clinic that was a CIC?     Yes     No

What type or organization?
 Sports Medicine Center / Hospital / Large Clinic      Small Doctor's Office with 3-5 Doctor / Small Clinic
Individual PhD / MD

Organization:

Organization Name:
Address:
City:
State / Zip:		Country:
Clinic Phone:		Fax Number:
Primary Contact:		Position/Title:
Phone Number:		Email:
2nd Contact:		Position/Title:
Phone Number:		Email:
3rd Contact:		Position/Title:
Phone Number:		Email:

Organizational Setting:

Hospital/Clinic	Group Practice	Private Practive	Other:
High School	College/University	Professional Team

Educational Background:
Give a brief history of your education including schools attended, graduation dates, majors, etc.:


Professional certifications/licenses:
Note any professional licenses, certifications and special training received. Include state, year and license number:


Membership in professional organizations:

AACAP	AAFP	AAN	AAP	ACA	ACSM
AGP	AGS	AMA	AMSSM	AOSSM	AOTA
INS	NAN	NASP	NATA	APA   (Psychiatric)	APA   (Psychological)
Other: