Illinois Prairie State Chiropractic Association

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Description	Dues Payment
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Recurring Payment	$250.00 Quarterly auto-debits starting 08/09/2025

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I authorize Illinois Prairie State Chiropractic Association to debit the account listed hereon $250.00, & agree to perform the issuer obligations. I authorize Illinois Prairie State Chiropractic Association to auto-debit the account listed hereon $250.00 Quarterly starting 08/09/2025 & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct.

Illinois Prairie State Chiropractic Association
PO Box 4174 Rock Island, IL 61204
(309) 797-9799

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