2014 - 2015 PAC Membership Form July 1, 2014 through June 30, 2015

PAC A

M S

Name Office Address City/State/Zip Office Phone E-mail Address

Fax # Select PAC Membership Level

PAC membership is an annual commitment from July 1, 2014, through June 30, 2015 Quarterly Annually

Ambassador Membership $250.00 $187.50 $1,000.00

Ambassadors are a prestigious group of chiropractic physicians committed to the advancement of chiropractic and have gone above and beyond the highest level of support through their generous contribution. Ambassadors receive special recognition at the PAC Reception during the MSCA Summer Convention. Scholar Membership

$750.00

Scholar members are a distinguished group of chiropractic physicians committed to the advancement of chiropractic. Scholars receive special recognition at the PAC Reception during the MSCA Summer Convention. Diplomat Membership

$125.00 $62.50 $500.00

Diplomats are a dedicated group of chiropractic physicians committed to the advancement of chiropractic. Diplomats are recognized at the PAC Reception during the MSCA Summer Convention. Emissary Membership

$30.00 $250.00

Emissary members are a special group of chiropractic physicians who give something extra to help support the advancement of the chiropractic profession. Regular Membership

$120.00 Regular members are chiropractic physicians who actively support the advancement of the chiropractic profession.

Aſter you have paid your annual PAC membership, purchases at any PAC-sponsored event apply toward reaching the next higher level of membership. Certain individual political contributions may also apply toward reaching the next level of membership. Doctors are responsible for notifying the MSCA office when additional donations are made. MSCA membership is not required to become a PAC member.

Method of Payment: Convenient payment plans are available. Dues can be automatically charged to your

credit card semi-annually or quarterly. Apply online at www.mscainfo.com *Important: For your convenience, automatic credit card charges continue annually. You may call to cancel at any time.

Please bill $ Annual *Semi-Annual

to my Visa MasterCard Discover *Quarterly

Monthly

Credit Card Number _______________________________ Expiration Date__________________________ Name as it appears on card __________________________ 3-Digit V-Code __________________________ Signature ________________________________________

Make checks payable to MSCA PAC and mail to: MSCA PAC, 220 E. Dunklin, Jefferson City, MO 65101. Phone: 573-636-2553. Fax: 573-635-1470.

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