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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

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