Membership Application | Texas Chiropractic Association | Austin, TX

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Membership Application

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Main Contact

First Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Middle Initial Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Last Name Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Home Address 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Home Address 2 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Home City Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Home State

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Cell Phone Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Home Phone Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Email Required Please enter a valid number Please enter a valid date Please enter valid credit card information Must be a valid email address

TBCE License # (fillable with n/a) Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Clinic/Business

Clinic/Business Name (fillable with n/a) Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Business Address 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Business Address 2 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Business City Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Business State

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

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

Business Website Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Business Email Required Please enter a valid number Please enter a valid date Please enter valid credit card information Must be a valid email address

Clinic Mailing Address (if different from physical address)

Address 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Address 2 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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

State

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

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

Total Contributions

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

Additional Item 4 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 5 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 6 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 7 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 8 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

Additional Item 9 Cost Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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

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

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

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

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

Temp Value For DropDown 1 Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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 Item 9

Additional Item 10

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
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

One-Time Application Fee

Tax

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

Mastercard

Visa

Discover

Amex

Credit Card Number Required Please enter a valid number Please enter a valid date Please enter valid credit card information

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City	Required
State
Zip	Required
Phone	Required
Credit Card Email Address

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Copyright Texas Chiropractic Association. All Rights Reserved.
1122 Colorado St, Ste 307 | Austin, TX 78701
Phone: (512) 477-9292 | [email protected] | sitemap

Membership
Events & CE
Advocacy
Corporate Partners
News & Ads
For Patients
- Find a Chiropractor
- Patient Resources
About TCA