Membership Application

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Maine Chiropractic Licensing Requirements

Proof of undergraduate degree or diplomate (copy allowed)
Proof of Chiropractic degree (copy allowed)
Copy of Chiropractic School transcripts (typically provided by school)
Exam scores from the National Board of Chiropractic Examiners – you must have passed Parts I, II, III, IV and Physi otherapy.

Licensing application fee is $100.00 and there is a one time fee of $21.00 for the criminal background check.

If you have been licensed in any other state previously, you will also need to provide a copy of that license.

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.

Step 1 of 2

Name
First Last
Date of Birth
MM slash DD slash YYYY
Occupation
Spouse's Name
Home Address
Office Address
Mailing Address
Home Phone
Office Phone
Fax #
Email
Years in Practice
Chiropractic College
Graduation Year
Are you licensed in Maine?
- Yes
- No
Year Licensed
License Number
Has your chiropractic license ever been suspended or revoked in any state or have you had any disciplinary actions against you?
- Yes (if yes, please attach an explanation)
- No
Explanation of Licensing Issues
Please list any local, state or national chiropractic organizations you are a member of
Please indicate any university or undergraduate program that you have completed with the degree obtained
Sponsor Name
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.

Membership Fee
Membership Fee
Price:
The application fee will be applied to membership dues and you will be billed those once membership granted.
Membership Type*
- Associate Doctor
- Doctor Owner
- Practicing Spouse of Member
- Active Retiree
Total
$0.00
Billing Address
Street Address Address Line 2 City State ZIP Code
Billing Phone
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Anti-Spam

Maine Chiropractic Licensing Requirements

Application for Membership

Step 1 of 2

Membership Fee