Name:__________________________________ Date of Birth:____________Social Security No.:____________________

Business Address:_____________________________________ County:______________ Congressional District:______

City:____________________________________ State:_____Zip:___________________Website:______________________

Office Phone:____________________________ Fax:__________________________ Email:___________________________

Home Address:_________________________________________ City:_____________________________________________

State:_____ Zip:_________________ County:___________________Home Phone:__________________________________

Cell Phone:__________________________________ Spouse's Name:_____________________________________________

State Representative:_______________________________ State Senator:________________________________________

Chiropractic College:____________________ Graduation Year:______ License Year:______ License Number:_______

Other State Licenses Held:________________________________________________________________________________

Other Degrees/Certifications:_____________________________________________________________________________

Are you now or have you ever been subject to a disciplinary action by a Chiropractic Association or licensing board? ____________ If yes please explain on a seperate sheet of paper and enclose.

Has your chiropractic license ever been suspended or revoked by any state? __________
If yes please explain on a seperate sheet of paper and enclose.

Veteran? ____________________ Branch / Dates:_______________________________________________________________

Membership Agreement: I hereby apply for membership in the Arkansas Chiropractic Association. I agree to abide by the constitution and bylaws, code of ethics, and all amendments, regulations, and motions adopted by the membership of the board of directors, as provided for in the constitution, and the bylaws of the state of Arkansas. It is mutually agreed that this application, when accepted shall constitute the full contract between the ACA and its members. I understand that failure to remit dues will result in loss of membership and all rights and privileges thereof.

Signature:____________________________________________________________Date:_______________

___ $400 Full Membership ___ $ 50 1st Year Graduate (1st Yr.) ___ $200 2nd Year Doctor (2nd Yr.)

___ $15 Student Membership ___ COMP Life Membership (70+ Yrs) ___ $50 Out of State Membership

___ Check Enclosed (Full Amt) ___ Credit Card (Full Amt) ___ Bill Credit Card Semi-Annually ___ Bill Credit Card Quarterly ___ Bill Credit Card Monthly

Credit Card Information: Name on Card:______________________________________________________

Card Number:___________________________________________ Exp.Date:___________________________