Illinois Prairie State Chiropractic Association

THANK YOU FOR YOUR MEMBERSHIP

Order Details
Description	Application-General 2nd/3rd Yr DC Member (Annual)
Total

Contact / Shipping
First Name*
Last Name*
Email*
Verify Email*
Address*
City*
State*
Zip*
Phone*
Office Address, City, State, Zip*
Office Telephone*
Booth Space*
Illinois License Number*
Year IL License Obtained*
Chiropractic College
Graduation Year*
Other Professional Organizations*
Active Practice*
Scientific Instruments Used
Techniques in Practice*
Billing Type (Yearly, Monthly)*

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 authorize Illinois Prairie State Chiropractic Association to debit the account listed hereon $250.00, & 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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