International Chiropractors Association

September 2, 2010

If you prefer to fill out and mail in a form, please click here for printable version.

ICA Membership Application *required fields
First Name*
Middle Initial
Last Name*
Date of Birth
Office Address*
City*
State/Province*
Postal Code (Zip)*
Country*
Office Phone*
Fax
Email Address*
Website Address

Home Address
City
State/Province
Postal Code (Zip)
Country
Home Phone	( )
Cell Phone	( )

Chiropractic College Attended
Graduation Date	Month: Year:
Chiropractic licenses held in:	Please List All
Notes or Questions:
Engaged in active practice?	Yes No
Former SICA member?	Yes No
Former Field member?	Yes No

MEMBERSHIP CATEGORIES
FIELD MEMBERSHIP Select from the membership categories below:
Total Amount	$
Auto-Pay Option. Set your membership up on convenient automatic payments. I authorize the ICA to automatically charge my credit card for my quarterly / yearly dues.
* For verification purposes, please type in the numbers and letters that you see below then press the Submit button * Unless otherwise requested, correspondence will be sent to your office address. ** Not eligible to vote in ICA elections † Teaching 8 or more academic hours per week at an accredited chiropractic college. †† ICA dues are not deductible as a charitable contribution for income tax purposes, but may be deductible as a business expense.