Alliance of New Mexico Chiropractors

Chiropractor Emeritus Membership

The dues for a non-licensed, retired chiropractor

who does not want to renew a license is

FREE

You are able to attend the Annual Convention

but there are no voting rights with this membership.

Come hang out with us, tell stories and pass on your

wisdom to the younger generation!

Simply fill out the form below.

*All memberships subject to approval of the

Alliance of New Mexico Chiropractors Board of Directors.

*All memberships are for 1 year (12 months) from date of joining.

*Members with memberships that do not include

CE relicensure are welcome at CE events.

Contact / Shipping

Title

First Name*

Last Name*

Email*

Verify Email*

Address*

City*

State*

Zip*

Country*

Cell*

Birthday

Practice Name

Company name

Techniques Practiced

Chiropractic College

Graduation Date

State Licenses Held

Date First Licensed

Recommended By

National Chiropractic
Organization Affiliations

Areas of Special Interest

Legislative Activities

Public Speaking

Public Relations

Research

Events

Philosophy

Teaching

Insurance Relations

Other Areas of Interest

Billing Address
Copy Contact
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

*Required

I affirm that the information entered on this form is true and correct.

The Alliance of New Mexico Chiropractors is

Certified Payment Card Industry Compliant for data security standards.

Alliance of New Mexico Chiropractors
3167 San Mateo NE, #144 Albuquerque, NM 87110
(505) 750-1302

To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.