(If You’re
Already A Member, Ask Another DC To Join!
Name
Practice or Company Name
Office Address
City/State/Zip
Office Phone
Fax Number
Office County
Home Address
City/State/Zip
Home Phone
E-mail Address
Date of Birth
Chiropractic College
Graduation Date
If student, Expected Graduation Date
Date & State of First Licensure
Missouri License No.
Select MSCA Membership Level
The MSCA membership year is January 1 through December 31, 2010.
Monthly
Quarterly
Annually
Regular Member
$33.33
$100.00
$400.00
Fourth-Year DC
25.00
75.00
300.00
Third-Year DC
16.66
50.00
200.00
Second-Year DC
8.33
25.00
100.00
First-Year DC
FREE
FREE
FREE
65 or Older
16.66
50.00
200.00
Faculty
16.66
50.00
200.00
Out-of-state
8.33
25.00
100.00
Associate (non-DC)
16.66
50.00
200.00
Student
($25 one-time charge or $10 annually)
10.00
I choose not to be a full member
at this time, but would like to help the MSCA in it’s fight to
defend, preserve and advance chiropractic for all chiropractors in the
state of Missouri by contributing as a donor.
Donor ($10-199)
The tax deductible portion of your 2010 MSCA dues has been calculated to be 82%. The non-deductible percentage is 18% and relates to our lobbying activities.
Billing Type
Method of Payment: Convenient
payment plans are available. Dues can be automatically charged to
your credit card semi-annually or quarterly, or they can be debited from
your checking account automatically every month.
*Important: For your convenience, automatic monthly debits and quarterly
charges continue annually. You may call to cancel at any time.
**Checking Auto Debit: To start automatic debit from your checking, please
call the MSCA office and a debit form will be sent to you.
Make checks payable to MSCA.
Credit Card Number
Expiration Date
Signature
Date
Make checks payable to MSCA and mail to:
MSCA, 220 E. Dunklin,
Jefferson City, MO 65101. Phone: 573-636-2553. Fax:
573-635-1470.
Missouri State Chiropractors Association 220 E. Dunklin
Jefferson City, MO 65101
Phone: 573-636-2553 -
Fax: 573-635-1470