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AMERICAN CHIROPRACTIC ASSOCIATION Council on Chiropractic Physiological Therapeutics & Rehabilitation Membership Application
Membership renewal or application fees are
$100/year.
GENERAL MEMBER: Any licensed Doctor of Chiropractic who is a member in good standing of the American Chiropractic Association shall be eligible for membership in this Council. STUDENT MEMBER: A chiropractic college student who is a student member in good standing of the ACA shall be eligible for student Name:___________________________________________________________________________ ADDRESS:________________________________________________________________________ CITY:____________________________________________________STATE:______ZIP:_________ FACILTY NAME:__________________________________________________________________ OFFICE PHONE: ( )____________________________ EMAIL:___________________________ OFFICE FAX: ( )_______________________________PAGER; ( )______________________ CHIROPRACTIC COLLEGE:_______________________________________________________ YEAR OF GRADUATION:__________________________________________________________ OTHER EDUCATION&DEGREES:___________________________________________________ _________________________________________________________________________________ I hereby apply for membership and confirm I am a member of the American Chiropractic Association and am In good standing with my state licensing board. I understand that failure to remit dues on July I" annually will result in loss of membership and all rights and privileges thereof indicated in the bylaws of the Council. Signature of Applicant:_______________________________________Date:______________ Mail to and make checks payable to :ACA Council on Chiropractic Physiological Therapeutic & Rehabilitation FCER ATTN: Cheryl Huff 380 Wright Road Norwalk, Ia 50211
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