Membership Application

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Name*
First Middle Last
Degrees
Clinic/Office Name*
Website

Please use http://www. in front of your website address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ADDRESS MUST MATCH ADDRESS OF THE CREDIT CARD USED FOR PAYMENT
Office Phone
Cell Phone*
Fax
Email*
Date of Birth*
Chiropractic College/Graduation Date*

Type Of Membership	Dues Monthly	Dues Annually
General Membership	$20	$240
Student	N/A	$20
Business and State Affiliates	$20	$240
New Practitioner (first two years after graduation	$10	$120

Please Select Membership Type:*
Please Select Billing Frequency: (General)
Please Select Billing Frequesncy: (Student)
Please Select Billing Frequency: (Business)
Please Select Billing Frequency: (New Practitioner)
Credit card payments are the only methods of payment accepted by AACP. Your credit card will be debited in the amount and frequency you designate
*the +/- amounts next to each option, denotes the amount added or subtracted to your total
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Signature*
By my signature, I agree to accept the bylaws as the governing rules of operation of AAPCM.
Name
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