MCA
Maine Chiropractic Assoc.
58 Albert Street
Lewiston, ME 04240

Executive Director/Robert Reed
email the Director
Voice: 207-622-5421
Fax: 207-782-5482

Founded in 1924

MCA APPLICATION FOR MEMBERSHIP

Effective Date_________________
Application for Membership
I HEREBY APPLY for membership in the Maine Chiropractic Association, Inc., for the purpose of serving the Chiropractic profession and for the benefits I may receive from such membership. If elected as a member, I agree to comply with the By-Laws of this association.
Name:________________________________________________ Date of Birth:____________________
Spouse’s name:_________________________________________ Occupation:_____________________
Children’s names and ages:_______________________________________________________________
Home Address:__________________________________________ Home Phone:___________________
Office Address:_________________________________________ Office Phone:___________________
Mailing Address:____________________________________________ Fax #:_____________________
City:___________________________________________________ Zip: _________________________
Number of years in practice:_________________ Email: ______________________________________
Of which chiropractic college are you a graduate? _____________________________ Year:__________
Are you licensed in Maine? ________ Year licensed:_____________ License Number:_______________
Have you been a member of the MCA? _____________________________________________________
Give name of any local, state or national chiropractic organization to which you belong: ______________
_____________________________________________________________________________________
Do you use any degree(s) or affiliation(s) in the HEALING ARTS other than “D.C.” after your name?
_____________________________________________________________________________________
List Degrees:__________________________________________________________________________
Above degrees were issued by which schools? _______________________________________________
List Undergraduate Degree(s) and university that issued:_______________________________________
_____________________________________________________________________________________
Do you agree, if elected, to keep the treasure informed at all times of your address, giving street number, etc.?___________
Date:______________________ Signature: _________________________________________________

SPONSOR:
This is to certify that I am a member in good standing of the Maine Chiropractic Association and do hereby recommend the above named Chiropractor for membership in the Maine Chiropractic Association.
Date:______________________ Signature: _________________________________________________

Deadline for application should be on or before March 1st prior to spring convention and on or before September 1st prior to the fall convention.
MCA c/o
John Royce
100 Albee Road
Augusta, Maine 04330
Return with NON-REFUNDABLE $25.00 application fee to:

Make checks Payable to:
Maine Chiropractic Association

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