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 APPLICATION FOR MEMBERSHIP

APPLICATION FOR MEMBERSHIP
New Application Update Information Pay Dues on Line
Name: First Last
Home Address:
City, State, Zip, Country: City State Zip County
Home Phone Numbers: ( )
Office Phone Number: Office ( ) Fax ( )
Office Address:
Office City, State, Zip, Country: City State Zip County
Doctor E-mail Address: License Number: 
License Number:
Date Practice Began: // (MM/DD/YYYY)
FULL - Time Practice
PART - Time Practice
Educational Background: FROM WHICH CHIROPRACTIC COLLEGE DID YOU GRADUATE?

Month/Year Graduated

DEGREES/POSTGRADUATE DEGREES (BA, D.C., Diplomats, Fellowships, QME, etc.)

Month/Year
Date: // (MM/DD/YYYY)

DUES
ARE YOU AN ICA MEMBER?
Yes No		 NOTE: Membership in ICAC does not make you a member of ICA. Membership in ICA does not make you a member of ICAC. ICA and ICAC are independent of each other.
First Year Following Licensure $35 per month $ 35/Month
Second Year Following Licensure $52 per month $52/Mo.
Third Year Following Licensure $69 per month $69/Mo.
Corporate, Group Practice or Multiple Clinics - All using same tax ID Number* $138/Mo.
Associate Member - Non Practicing, non voting DCs (includes lay public) $75/Year
Clinical Faculty - Part time practice 1/2 Year
Graduate Member - Graduates until Licensure $65/Total
Student* (Until Graduation) - Date of Graduation - // (MM/DD/YYYY) $25/Total
Lifetime Membership $2,000.00/Total

PAYMENT
Amount remitted:
1 Year 1/2 Year 1 Quarter 1 Month 		Note: Student or Graduate dues is a one time fee paid in full on submission of application.
Method of payment:

To apply for discount, complete the Authorization for Payment form.

Complete this section ONLY if paying by credit card.
CREDIT CARD ACCOUNT NUMBER
EXPIRES: / (MM/YYYY)
NAME (As it appears on credit card.)
Membership Password (for future updates)
   
If I am accepted for ICAC Membership, I hereby agree to the ICAC Bylaws and Code of Ethics, as adopted and as may be adopted from time to time by the Board of Directors. X
ICAC Sponsoring Member or Organization (if applicable - is not required):

To apply for discount, complete the Authorization for Payment form.

*Please submit all licentiate names and applicable clinic addresses on letterhead stationary. Send to address below.

International Chiropractors Association of California
Membership Committee
9700 Business Park Drive, Suite #305
Sacramento, CA 95827-1718
Phone: (916) 362-8816 (800) 275-3515 FAX (916) 362-4145

Membership Dues Discount

Discounts are given for either, 1) prepayment of a full year of dues, or 2) payments pre-authorized and automatically paid by either credit card or automatic debits to checking account. If you wish to apply and receive $120 annual reduction in dues, please complete the following Direct Payment Authorization.

DIRECT PAYMENT AUTHORIZATION
and Agreement for $120 per Year Reduction in Dues
I hereby authorize the International Chiropractors Association of California (ICAC) to initiate debits and credits to my checking account per attached voided check below, or to charge to my credit card account as authorized on my ICAC Application for Membership. By forwarding this agreement, I understand I am receiving a $120 per year reduction in dues.

FULL ONE YEAR DUES PAYMENT

First Year following licensure - full one year dues payment $ 300
Second Year following licensure - full one year dues payment

$ 504

Third Year following licensure - full one year dues payment $ 708
Corporate, Group Practice or Multiple Clinics - all DCs using same tax ID number $ 1,416

AUTOMATIC MONTHLY DEBIT OR CREDIT CARD
($120/YR OFF MONTHLY FEES)

Day of month to debit account: of each month. DUES
First Year following licensure

$25/month

Second Year following licensure $42/month
Third Year following licensure $59/month
Corporate, Group Practice or Multiple Clinics - all DCs using same tax ID number $116/month
Tax ID Number for Corporation or Partnership  

METHOD OF PAYMENT

I authorize the ICAC to debit my account by EFT (Electronic Funds Transfer) or by credit card as stated above each month for the agreed upon payment amount and on the same date each month thereafter, until canceled as stated below.

I authorize the bank, per attached check, or credit card company to make payment on my behalf to the ICAC. I understand that I am in full control of my payment. I can stop this automatic direct payment at any time by writing or calling the ICAC.

I have read, understand, and agree with the terms of this form.

For Automatic Debit to Bank Account

For automatic monthly debiting of bank account, please print this form, complete and sign the account information below, attach a voided check and mail to the ICAC with completed membership application.

(If corporation, a corporate officer must sign. If partnership both partners must sign.)
(If a two signature check, both parties must sign.)

   
Signature
X__________________ 		Name of signature on Account
 		Title
Date
Signature
X__________________ 		Name of signature on Account
 		Title
Date

 

Return to Top of ICAC Application
If applicable
Print and Attach a Voided Check Here

 

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