MEMBERSHIP APPLICATION
Please print this application and mail or fax it to the WCA

Are you applying for Student of Regular Membership?			Student Regular (check one)
First Name:		M.I.:		Last Name:
Nick Name:					Spouse's Name:
Office Name:
Office Address:
Office City, State, Zip:
Office Phone No.:					Office Fax #:
Home Address:
Home City, St, Zip:
Home Phone #:					Cell Phone #:
Date of Birth:	E-Mail Address:
School Currently Attending:						Expected Graduation Date:
WI License No.:	Date Issued:

I hereby apply for membership in the Wisconsin Chiropractic Association and include a non-refundable application fee of $20.00.

I understand that my application is subject to District and Board of Directors approval, and that I will be notified of their action. I agree that if my application is accepted, I will abide by the Code of Ethics and Bylaws of the
Wisconsin Chiropractic Association and I agree to conduct my practice in accordance with the statues governing the practice of chiropractic in the State of Wisconsin and the rules set forth by the Wisconsin Chiropractic Board of Examiners.
**(Different rates may apply to out of state memberships. Please contact our office for more information

Date: _____________________________

Signature: _________________________________

Included is a check or money order for my non-refundable application fee of $20.00.
**OR**
Please charge my: VISA MastercardCard

Number: _______________________________ Exp.: _____________________
Cardholder's Name: ________________________________________________

To become a member of the WCA, simply complete this application and fax it to (608)256-7123.
OR send it with your application fee to: WCA, 521 East Washington AVenue, Madison, WI 53703.

FOR OFFICE USE ONLY
Rate begin:	District:	Senate:	+4:	Mem1000:
Status:	County:	Assembly:	CE:	Dues Forecast:

 

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