(Please Print)

Name: ___________________________________________________________________________

Address: _________________________________________________________________________

City: ___________________________ State: ______________ Zip: _________

Phone: H(_____) ___________              W(_____) ___________

FAX(_____) ___________                   E-Mail: _____________________________________________

Chiropractic School___________________________       State of Current Licensure________________

To better meet your needs, we would appreciate your answers to the following questions:

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)      Renewal - $120     Student Member- $40

Corporate Member - $500         Collect Member - $500         Associate Member (non-DC) $90

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 Medicine as part of their dues at no extra charge.