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APPLICATION FOR INCLUSION IN THE FINDLIEN.COM DATABASE Membership includes         * Inclusion in FINDLIEN.COM database         * Web page located at: http://www.findlien.com/[yourloginname] Fill out the following index information, and then click the button below to submit the information. Next, you will be asked to check all applicable medical categories. The cost for inclusion in the database is $49.99, annually, unless you have been provided with a "promotional code," which should be entered below. Index Information ( required Fields denoted by a * ): Facility Name * Contact Person * Street Address * City * Zip Code * County * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Country * Australia France Germany Japan United Kingdom United States Telephone * Fax E-Mail * Web Site Log-In Name * Password * Promotional Code YOUR LOG-IN NAME AND PASSWORD ARE FOR USING "MEMBER SERVICES" TO MAKE CHANGES TO YOUR LISTING AND TO VIEW STATISTICS RELATED TO YOUR LISTING YOUR LOG-IN NAME WILL BE THE SAME NAME AS THE FREE WEB PAGE THAT WE PROVIDE YOU (e.g., WWW.FINDLIEN.COM/[LOGIN NAME]). THIS LOG-IN NAME CANNOT BE CHANGED USING MEMBER SERVICES, BUT WILL REQUIRE E-MAIL NOTICE AND A SMALL PROCESSING FEE. DISCLAIMER: DOCTORS PARTICIPATING IN THIS DIRECTORY HAVE BEEN REQUIRED TO SUBMIT A CURRENT LICENSE TO PRACTICE A PARTICULAR AREA OF MEDICINE. NOTWITHSTANDING, YOUR USE OF THIS SYSTEM IS WITH THE UNDERSTANDING THAT THERE ARE NO GUARANTEES AS TO THE EFFECTIVENESS OF THE TREATMENT NOR ANY GUARANTEES AS TO THE VALIDITY OF ANY LICENSES PROVIDED TO OUR COMPANY BEFORE A HEALTH CARE PROVIDER'S LISTING HAS BEEN PLACED ONLINE. THE USER, BY USING THIS SYSTEM, ACKNOWLEDGES THE ABOVE AND USES THIS SYSTEM AT HIS OR HER OWN RISK.