[ by holding down Ctrl key and pressing P key, this page will print out ]

Name _______________________________________________________________
( Dr. / Ms./ Mr. )                                                                                                Degree(s)

Name of business ___________________________________________________

Street Address ______________________________________________________

Town _______________________________ State ___________ Zip _____________

Telephone: (O) _______________  (F) ___________________ (H)  ____________________

E-Mail Address _______________________________________

Affiliations w/ chiropractic organizations (include educational, professional and political institutions)
 
 
 
  If Doctor of Chiropractic, School and year of graduation ___________________________

States licensed __________________________________________________

If chiropractic student, school and anticipated time of graduation________________

Check appropriate level for which application is made

___ REGULAR MEMBER (Full membership privileges and voting) $100 annual dues
___ STUDENT MEMBER (Chiropractic students and doctors having graduated within 2 years / Full privileges and voting) $25 annual dues

Signature _____________________________