DC Member Application Please enable JavaScript in your browser to complete this form.Name *Who referred you?Email *EmailConfirm EmailPhone *Clinic NameMailing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLicense Number *License issue date *Other states you are licensed in *Separate each with a commaNumber of years licensed in Washington *N/A>1 year1-2 years2-3 years3+ yearsWhich membership are you applying for? *StandardOlympicRainerRetiredSemi-retiredOut of StateStudentBilling preference *Annually: $665.00Semi-anually: $332.50Quarterly: $166.25Monthly: $55.42Billing preference *Annually: $420.00Semi-anually: $210.00Quarterly: $105.00Monthly: $35.00Membership dues for 3rd year licensees are partially subsidized.Billing preference *Annually: $240.00Semi-anually: $120.00Quarterly: $60.00Monthly: $20.00Membership dues for 2nd year licensees are partially subsidized.Billing preference *FREEMembership dues for 1st year licensees are fully subsidized.Billing preference *Annually: $2100.00Semi-annually: $1050.00Quarterly: $525.00Monthly: $175.00Billing preference *Annually: $1500.00Semi-annually: $750.00Quarterly: $375.00Monthly: $125.00Billing preference *Annually: $150.00Retired, Semi-retired, Student, and Out of State memberships must be paid annually.Billing preference *Annually: $70.00Retired, Semi-retired, Student, and Out of State memberships must be paid annually.Billing preference *Annually: $40.00Retired, Semi-retired, Student, and Out of State memberships must be paid annually.EducationChiropractic College attended *Attended an institution no longer in operationAttended an institution outside of the United StatesCleveland UniversityD’Youville CollegeKeiser UniversityLife Chiropractic College West (CA)Life University (GA)Logan UniversityNational University of Health SciencesNorthwestern Health Sciences UniversityPalmer College of Chiropractic (FL)Palmer College of Chiropractic (IA)Palmer College of Chiropractic West (CA)Parker UniversitySherman College of ChiropracticSouthern California University of Health Sciences (formerly LA College of Chiropractic)Texas Chiropractic CollegeUniversity of BridgeportUniversity of Western StatesNone IdentifiedIf closed or out of stateGraduation date *Languages spoken *AfrikaansAmerican Sign LanguageAmharicArabicArmenianBantuBengaliBulgarianChinese (Cantonese)Chinese (Mandarin)Chinese (Taiwanese)CushiteDariDutchEnglishFarsiFinnishFrenchGermanGreekHaitian CreoleHebrewHindiHmongHungarianItalianJapaneseKhmerKoreanLaotianNorwegianOtherPolishPortuguesePunjabiRomaniRussianSamoanSerbo-CroatianSomaliSpanishSwedishTagalogTamilTeluguThaiTurkishUkranianUrduVietnameseYiddishTechniques *Advanced Biostructural CorrectionActivatorApplied KinesiologyANATOMActive ReleaseAtlas Orthoganal/Upper CervicalBESTBiophysicsBLAIRBiomechanicsBrimhallCADJChiropractic BiophysicsCold LaserCOXCox Flex/DistractionCranial FacialCSPCSTHDISCDiversifiedDTEXFull SpineGENGonsteadGrastonIntersegmental TractionLeanderLeander TechniqueMANUALMassageMICROMMotion PalpationMyofascial ReleaseNeuromotional TechniqueNIMMONUCCAPettibonPierce/StillwellPalmer PackagePierce/StillwellPTLMSSacro Occipital TechniqueSweat Adjusting TechniqueThompson DropToftnessToggle RecoilTORQRTrigger Point TherapyNone IdentifiedSpecialties *American Board of Nutrition and Neurochem (Fellows of the American College of Functional Neurology)American Chiropractic Board of RadiologyCertified Chiropractic Extremity PractitionerCertified Chiropractic Sports PractitionerCertified Clinical NutritionistCertified Kinesio Taping PractitionerChiropractic Certification in Spinal TraumaDiplomate American Board of Chiropractic OrthopedistsDiplomate American Chiropractic Neurology BoardFellows of the American Academy of Chiropractic OrthopedistsNutritionPediatricsRehabilitationSports ChiropracticNone IdentifiedServices *CACMassageNutritionPediatricsRehabilitationSports ChiropracticStudent RecruitmentTelehealthWCTNone IdentifiedWebsite / URLAdditional CC EmailEmailConfirm EmailSubmit
