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Main Contact

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Home State

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Clinic/Business

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Business State

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Clinic Mailing Address (if different from physical address)

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State

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Membership Type and Contributions

Membership Type

Payment Plan

Primary Directory Category

Optional Contributions

Chiropractic Development Initiative (CDI)

Legal Defense Fund

Political Action Committee (PAC) Contributions

Membership Dues $0.00

Total Contributions $0.00

Total

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Full-Time Employees Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Part-Time Employees Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Hotel/Motel Rooms Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Restaurant Seats Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Associates Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Associates Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Locations Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Locations Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Assets Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Assets Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Categories Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Number Of Additional Categories Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Categories Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

CDI Contribution Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Legal Defense Fund Contribution Required Please enter a valid number Please enter a valid date Please enter valid credit card information

PAC Contribution Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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Additional Item 10 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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Revenue Item Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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Fee (charged to card) Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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Membership Type Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Payment Plan Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 1

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Additional Directory Categories

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Secondary categories may be subject to additional fees

Number of Full Time Employees

Number of Part Time Employees

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Additional Categories Cost $0.00

One-Time Application Fee $0.00

Tax $0.00

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Credit Card Information

Copy from Clinic/Business Information

Credit Card Type

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Amex

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1122 Colorado St, Ste 307 | Austin, TX 78701
Phone: (512) 477-9292 | info@chirotexas.org | sitemap

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