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MEMBERSHIP APPLICATION & DUES
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Year_______ |
Membership______ |
Renewal______ |
New Member______ |
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PLEASE PRINT - If you are a new member, please provide all information requested in items 1 through 9. If renewing, please provide any
changes
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| Name:_________________________________________ |
M/F_______________ |
| Office Address:_________________________________ |
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| City:_______________________State:______________ |
Zip:_______________ |
| County:______________Office Phone______________ |
Fax:_______________ |
| Email:_________________________________________ |
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| Date of Birth:_________Married:_______Single:______ |
Spouse Name:______ |
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___________________ |
| Chiropractic College:____________________________ |
Grad Date:__________ |
| Other College(s) attended:_______________________ |
Degree R'cd_________ |
| Board certified in these specialty areas:________________________________ |
| To what other Chiropractic Associations do you belong?_________________ |
| __________________________________________________________________ |
| Do you have a valid NM Chiropractic License?_______ |
Lic # ______________ |
| When did you begin practicing in New Mexico?_________________________ |
| In what other states are you licensed to practice?_______________________ |
| Techniques used in practice include:__________________________________ |
I further agree to abide by the bylaws of the state association, to strive to attend association conventions regularly and to take part in my district
meetings to the best of my ability. I further understand that by providing my fax number and/or e-mail address, I agree to receive faxes and/or e-mails
sent by or on behalf of the NMCA. |
Date:_____/______/_____Applicant Signature___________________________
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Membership
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(All dues are calendar year)
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TOTAL: |
Regular Member: |
$500 annually, to be paid
_____ monthly _____annually |
$_______
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$250 annually for Doctors working part time due to impairment or illness, confirmed by physician
_____ monthly _____annually
$250 annually for previously licensed DC NEW to NM
____monthly _____annually
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$_______
$_______
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New Licensee: |
$0.00 annually (within 1st 12 months), $100 annually (within 2nd 12 months), & $200 annually (within 3rd12 months) for DCs just out of Chiropractic College |
$_______
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Out-of-State Doctor: |
$150 annually (licensed DC practicing outside NM) |
$_______ |
Student: |
$25 annually |
$_______ |
Professional Associates: |
$150 annually (non-DC business or individual) $_____ |
$_______ |
Honorary Member: |
Exempt from dues (retired and age 60+ or disabled) |
$_______
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Early Renewal: |
If paid in full by 12/31 before membership year, - 10% |
$_______ |
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CONTRIBUTIONS |
| PAC: |
Non-deductible political action contribution fund |
$_______ |
| President's Circle: |
Non-deductible discretionary, legislative & lobbyist fundMember: $1,000 or more; Associate: $1-$999 |
$_______
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| Scholarship Fund: |
Contribute to helping new Doctors of Chiropractic |
$_______ |
| PR Media Fund: |
Making Chiropractic visible throughout NM |
$_______ |
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Total Dues and Contributions |
$_______ |
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Use the EZPay for your convenience!! |
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I am applying as a ___________________ member. Enclosed is |
$_______
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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
505-280-0689
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