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New Member Application

Special Application Certificate $125 Off D.C. Full General Membership*

ACA- New Jersey

(Print this page, complete & mail to ACA)

Name (please print)____________________________________ Referred by : Frank A. Stiso,D.C.
Address:_______________________________________________________________________________

Office Phone(_____)_____________________ Home Phone(_____)_____________________ Fax(_____)______________________
E-Mail______________________ Chiropractic College _______________________Degree_______ Date of Graduation__________

*This is a one-time offer to join/rejoin the ACA for a reduced payment of $475 for the first year of D.C Full General dues. This offer is for a limited time only and cannot be combined with any other special offer to join the ACA. Annual dues payment or enrollment in EZ Pay must accompany this completed membership application to validate this offer. Membership application is subject to review and approval by ACA's Membership Committee. Valid only to those who have not been ACA members for at least 12 months. Annual dues include $90.00 for a subscription to the Journal of American Chiropractic Association. In 2003, Ninety-three percent of ACA membership dues may be deductible as an ordinary and necessary business expense. In applying for membership, I certify that I am registered and/or licensed. I understand that my application is subject to ACA Board approval, that will I will be notified of its action, that failure to remit will result in loss of membership, and that membership includes all rights and privileges as provided in ACA Bylaws. I pledge to ascribe to ACA's profound commitment to top quality care, professionalism, and ethics. I respect the unique individuality of my patients and am dedicated to protecting and preserving their rights.

Applicant Signature:______________________________ Date:_________
1701 Clarendon Blvd Arlington VA 22209 * 703/276-8800 * Fax 703/243-2593 * memberinfo@amerchiro.org * www.acatoday.com

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Mail or Fax to: The American Chiropractic Association, 1701 Clarendon Blvd, Arlington, VA 22209.
Fax (703)243-2593

Frank A Stiso, DC,. New Jersey State Delegate. 732-381-0375 or fasdc@hotmail.com