WCA

(800) 347-1011

World Chiropractic Alliance Membership Enrollment Form

 World Chiropractic Alliance Membership
Enrollment Form

Yes! I want to support subluxation-based chiropractic by joining the World Chiropractic Alliance. By doing so, I am helping achieve the goal of a subluxation-free world through a vision of worldwide wellness.

Category (check one)
[  ]  Doctor of chiropractic within the United States: $99 per quarter or $396 per year.
[  ]  Doctor of chiropractic outside Canada and the United States: U.S. $99 semi-annually or U.S.$198 per year.
[  ]  Chiropractic student: $30  (a one-time charge that covers membership dues while in chiropractic college and for 12 months following graduation or until licensure has been granted, whichever occurs first.)Graduation date ______________________________________.
[  ]  Full time faculty in a chiropractic college: $99 per year

Name: __________________________________________________________________________

Address: ________________________________________________________________________

City/State/Zip:  ___________________________________________________________________

State/Province: ______________________________________________ Country: _____________

Phone: _____________________________________ Fax: ________________________________

E-Mail: _________________________________________________________________________

If paying by credit card:      Credit Card: [   ] Visa     [    ] MC       [    ] Amex

Card Number: __________________________________________________________________

Name as it appears on credit card: _________________________________________________

Billing address (if different than above): ______________________________________________

Expiration date: _______________________________________________________

Signature of Card Holder: ________________________________________________________

I authorize the World Chiropractic Alliance to charge the credit card listed above automatically for recurring quarterly, semi-annual or annual membership payments and renewals until I instruct the WCA, in writing, to terminate my membership.

Authorization signature: __________________________________________

Please print this form, fill it out completely, and send it with payment (in $US) — or credit card information — to:
World Chiropractic Alliance, 2683 Via de La Valle Suite G 629 Del Mar, CA 92014
OR fax with credit card information to: 1-866-789-8073
OR call 800-347-1011 (within the U.S. and Canada)

NOTE: For Doctors of Chiropractic in Canada: print out the WCA-Canada application (pdf format, requires Adobe Acrobat reader, available free from Adobe)