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Name and Degree(s): ______________________________________________

Address: _________________________________________________________

City: _______________________ State: _____ Zip: ____________

Phone: H(____) ______________              W(____) _______________

FAX(____) ___________         E-Mail: _______________

Office Website: ___________________________________

Chiropractic School_________________   


State of Current Licensure___________________

To better meet your needs, we would appreciate your answers to the following selections:
BOARD CERTIFICATIONS
____Radiology                                            _____Neurology
____Family Practice/Internal Medicine            _____Nutrition
____Orthopedics                                        _____Behavioral Health
____Occupational Health                             _____Physiological Therapeutics
Sports Medicine ____________
Radiology

PRACTICE
____Private Practice                                   _____Oriental Medicine
____Outpatient Clinic                                  _____Acupuncture
____Faculty / Teaching                               _____Clinic Multi-Disciplinary
____Occupational/Rehabilitative                    _____Group Practice
____Preventive Medicine / Wellness               _____Other

Membership Type

CFP (New Member First Year $150 USD)   ________  


Renewal - $120 (USD)  _________   


Student Member- $40 (USD)_______

Corporate Member - $500 (USD) _______   


Collect Member - $500 (USD)  ________      


Associate Member (non-DC) $90 (USD)  ________

Please accept my additional contribution of $ _________ to further the work of the Council


By completing and signing this application for membership, the applicant supports and fosters the tenets and purposes of CDID. Lack of support and fostering of the tenets and purposes of CDID will lead to denial or revocation of membership.

Each dues paying member receives an annual subscription to the Journal of Chiropractic Internist as part of their dues at no extra charge.

Make Check Payable to:   CDID

Or pay by visa or mastercard ___________________________________exp___________

Three digit code on the back of your card____________.

and fax to 920-682-6983

Forward Application & Payment to: 

CDID-ACA

Attn: Loretta Brandl

3713 Calumet Avenue

Manitowoc, WI 54220