CPM Information Release Consent Form

Occasionally NARM receives requests for listings of CPMs in specific areas. While NARM will verify that a midwife is a CPM if asked, we cannot release names or any other information without prior authorization. If you would like this information released, please print and sign the form below and mail to:

NARM Applications Department
P.O. Box 420
Summertown, TN 38483

Release Form

I, (print/type name)____________________________________ give permission for NARM to release my name as a CPM, including contact information, CPM number, CPM issue date, and CPM expiration date. This becomes effective on (date)___________________.  I understand that to revoke this permission, I must send notice in writing to the same address.

Current address:___________________________________________________

Current city, state, zip: ____________________________________________

Current phone: __________________

Current e-mail (if available): _____________________________

Current status:  ___ legally recognized (licensed, registered) by state, or___ no legal recognition by state

Signature: ___________________________________________________

Contact Us:

NARM Phone and
Fax Number

For all Departments

NARM General Information

Debbie Pulley
5257 Rosestone Dr.
Lilburn, GA 30047

NARM Applications and Testing Department

PO Box 420
Summertown, TN 38483

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