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Membership Application
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Specialty and Board Certifications
Has your license to practice in any jurisdiction ever been reprimanded, limited, suspended or revoked?
Yes
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Have you ever been involved in any malpractice litigation?
Yes
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Have you ever been suspended or removed from any provider participation panels?
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**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