LMHI -

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LIGA
MEDICORUM
HOMOEOPATHICA
INTERNATIONALIS

Family Name:

First Name:

Title(s):

Date of Birth:

Address:

City:

State:

Postal Code:

Country:

Phone:

E-Mail:

Academic qualification (medical, veterinarian, dentistry, pharmacy etc.):

Name of homeopathic institute / school:

Graduated on:

I will provide the photocopies of my university medical diploma (MD, Vet.,Dent.,or Pharmacist) and my homeopathic diplomas when requested.