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Membership Application

All materials will be sent to your email and your office address provided
unless otherwise notified.

Order Details
Description IPSCA Application Fee
Total
Contact / Shipping
First Name*
Last Name*
Email*
Verify Email*
Address*
City*
State*
Zip*
Phone*
Website*
Illinois License Number*
Year Obtained IL License*
Chiropractic College*
Graduation Year*
Other Professional
Organizations*
Presently Engaged In
Active Practice*
Former IPSCA Member*
Reason You Want To Join
IPSCA*
Scientific Instruments
Used*
Techniques In Practice*
Membership Type You're
Interested In*
Chiropractic Office
Address*
Billing Type*
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



By clicking on [Submit] I hereby apply for membership in the Illinois Prarie State Chiropractic Association, Inc., and am submitting an application fee of $25.00. I understand that my application is subject to membership approval and that I will be notified of its action. I hereby pledge my support to help preserve and advance chiropractic in the State of Illinois and agree to abide by the Constitution, By-Laws, and Standards of the IPSCA.

 

Welcome to the IPSCA

 

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