Illinois Prairie State Chiropractic Association

THANK YOU FOR YOUR DUES PAYMENT

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Description	Automatic Yearly Dues Payment
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Recurring Payment	$1000.00 Annually auto-debits starting 12/30/2026

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I authorize Illinois Prairie State Chiropractic Association to debit the account listed hereon $1000.00, & agree to perform the issuer obligations. I authorize Illinois Prairie State Chiropractic Association to auto-debit the account listed hereon $1000.00 Annually starting 12/30/2026 & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Illinois Prairie State Chiropractic Association Terms as referenced in the [Terms of Use] link below.

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

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