World Chiropractic Alliance Membership
Enrollment Form
 Yes!
I want to support subluxation-based chiropractic by joining the World
Chiropractic Alliance. By doing so, I
am helping achieve the goal of a subluxation-free world through a vision
of worldwide wellness.
Category (check one)
[ ] Doctor of chiropractic within
the United States: $99 per quarter or $396 per year.
[ ] Doctor of chiropractic outside Canada and the United States: U.S.
$99
semi-annually or U.S.$198 per year.
[ ] Chiropractic student: $30
(a one-time charge that covers membership dues while in chiropractic college and
for 12 months following graduation or until licensure has been granted, whichever occurs first.)
Graduation date ______________________________________.
[ ] Full time faculty in a chiropractic college: $99
per year
Name:
__________________________________________________________________________
Address:
________________________________________________________________________
City/State/Zip:
___________________________________________________________________
State/Province:
______________________________________________ Country: _____________
Phone: _____________________________________ Fax:
________________________________
E-Mail:
_________________________________________________________________________
If paying by credit card: Credit Card: [ ] Visa [ ]
MC [ ] Amex
Card Number:
__________________________________________________________________
Name as it appears on credit card:
_________________________________________________
Billing address (if different than above):
______________________________________________
Expiration date: _______________________________________________________
Signature of Card Holder:
________________________________________________________
I authorize the World Chiropractic Alliance to charge the credit card
listed above automatically for recurring quarterly, semi-annual or annual membership payments and renewals until I
instruct the WCA, in writing, to terminate my membership.
Authorization signature: __________________________________________ |
