920-450-6066

Become A Member

Membership Fee- $125

Membership Application

Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Email
Specialty and Board Certifications
Has your license to practice in any jurisdiction ever been reprimanded, limited, suspended or revoked?
- Yes
- No
Have you ever been involved in any malpractice litigation?
- Yes
- No
Have you ever been suspended or removed from any provider participation panels?
- Yes
- No
**If yes to any of the above, please submit a letter of explanation for consideration.
Important Instructions - Submit this application with a current curriculum vitae, recent photograph and a copy of your state license. An agreement contract will be forwarded to you that will require your signature and notarization.

Please send all required documents to:
American College of Chiropractic Consultants
8219 Kennedy Ave.
Highland, IN 46322

Membership payment QR Code

Membership in the ACCC is a selective process and is not guaranteed. All applications are carefully reviewed and discussed by the Board, with input from current members. The Committee and Board reserve the right to decline membership if it is determined that an applicant may not be the best fit for the organization at this time. While all applications receive full consideration, the ACCC may not provide individual feedback or correspondence regarding membership decisions.