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MEMBERSHIP APPLICATION & DUES
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Membership |
(All dues are calendar year)
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TOTAL: |
| Regular Member: |
$500 annually, to be paid
_____ monthly _____annually |
$_____ |
$250 annually for Doctors working part time due to impairment or illness, confirmed by physician
_____ monthly _____annually
$250 annually for previously licensed DC NEW to NM
____monthly _____annually
|
$_____
$_____ |
| New Licensee: |
$0.00 annually (within 1st 12 months), $100 annually (within 2nd 12 months), & $200 annually (within 3rd 12 months) |
$_____ |
| Out-of-State Doctor: |
$150 annually (licensed DC practicing outside NM) |
$_____ |
| Student: |
$25 annually |
$_____ |
| Professional Associates: |
$100 annually (non-DC business or individual) $_____ |
$_____ |
| Honorary Member: |
Exempt from dues (retired and age 60+ or disabled) |
$_____ |
| Early Renewal: |
If paying by December 31, deduct 10% |
$_____ |
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CONTRIBUTIONS |
| PAC: |
Non-deductible political campaign contribution fund |
$_____ |
| President's Circle: |
Non-deductible legislative expense & lobbyist fund
Member: $1,000 or more;
Associate: $1-$999 |
$_____ |
| Scholarship Fund: |
Contribute to helping new Doctors of Chiropractic |
$_____ |
| PR Media Fund: |
Making Chiropractic visible throughout NM |
$_____ |
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I am applying as a _________________________ member. Enclosed is |
$_____ |
I am paying by Visa # _____________________________Expiration Date: ______ |
I am paying by MC# ______________________________ Expiration Date: ______ |
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I am paying by Discover #_________________________ Expiration Date: ______ |
PLEASE REFER A COLLEAGUE:_________________________________________ |
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PLEASE MAKE OUT SEPARATE CHECKS FOR MEMBERSHIP, PAC AND PRESIDENT'S CIRCLE.
Please mail application with credit card information,
check or money order to:
NMCA, P.O. Box 21100, Albuquerque, NM 87154
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