MSCA 2014 MEMBERSHIP APPLICATION

Make checks payable to MSCA and mail to: MSCA, 220 E. Dunklin, Jefferson City, MO 65101. Phone: 573-636-2553. Fax: 573-635-1470 Online Application and submission also available at www.mscainfo.com.

Name Practice or Company Name

Office Address City/State/Zip Office Phone Fax Number Office County Chiropratic College Graduation Date Date & State of First Licensure

Home Address City/State/Zip Home Phone E-mail Address Date of Birth If student, Expected Graduation Date Missouri License No.

Select MSCA Membership Level Te MSCA membership year is January 1 through December 31, 2014. Monthly

Regular Member $33.33 Fourth-Year DC $25.00 $16.66

Tird-Year DC

Second-Year DC $8.33 FREE

First-Year DC

65 or Older Faculty

Quarterly

$100.00 $75.00 $50.00 $25.00 FREE

Out-of-state

Associate (non-DC) $16.66 Student

$50.00 $50.00 $25.00 $50.00

Annually

$400.00 $300.00 $200.00 $100.00 FREE

(First-Year DC based on first year licensed in Missouri.) $16.66 $16.66 $8.33

($25 one-time charge or $10 annually)

$200.00 $200.00 $100.00 $200.00 $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) 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.

Please bill $ Credit Card #

Name as it appears on Credit Card Signature

6 to my Annual Semi-Annual*

Visa MasterCard Quarterly*

Discover Monthly* Expiration Date Date July 2014 v Te Missouri Chiropractor 3-Digit V-Code AMEX Checking (Form required)

Te tax deductible portion of your 2014 MSCA

dues has been calculated to be 95%. Te non-deductible percentage is 5% and relates to our lobbying

activities.

If You’re Already A Member, Ask Another DC To Join!