Name

Date of Birth MM/DD/YYYY

How many years have you been in practice?

Office Street Address

Office City

Office State

Office Zip Code

Office Phone

Office Website

Office Email Address

Would you like us to add your office information to our "Find a Doctor" registry? Would you like us to add your office information to our "Find a Doctor" registry?YesNo

Mailing Address (if different than above)

City

State

Zip Code

Your Email Address

Home or Cell Phone #

Of which chiropractic college are you a graduate?

Year Graduated

Please list other degrees and education.

Are you licensed in New Hampshire? Are you licensed in New Hampshire?YesNo

Year Licensed

New Hampshire License Number

Please list any other states you are licensed in.

Please list all professional association memberships.

Were you referred by one of our current members?

Please check all committee positions you may be interested in: Please check all committee positions you may be interested in: Membership By-Laws Legislative Continuing Education Radiological Public Relations Insurance Relations Ethics Auditing Resolution Peer Review Health Planning

Understanding of Dues Payment Understanding of Dues Payment I understand that my NHCA membership will be discontinued if I fail to pay annual dues.*