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Legal Action Fund
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Fighting For Chiropractic Donation Form

ACA- New Jersey

CONTRIBUTION OPTIONS: (Check One)
( ) $100  A MONTH
( ) $200  A MONTH
( ) $500  A MONTH
( ) $1000 A MONTH
( ) OTHER: A MONTH $_____________ 
( ) ONE TIME DONATION $____________
 
Payment Type (Check One)
( ) Check Attached
( ) Credit Card:  ___Visa     ___Mastercard     ___Discover    ___AMEX
 
Card#:___________________________      Expires:______________
 
I hereby authorize the National Chiropractic Legal Action Fund to initiate, on or about the 15th of each month, debit entries to my credit card account.  This aggreement will remain in effect unless I notify NCLAF, in writing, to cancel it.
 
 
Print Name:____________________________   Today's Date:__________ Address:_______________________________  City:__________________ 
State:___  Zip______  Office Phone:__________ Other Phone:__________ Fax:__________________  Email:___________________________ 
 
Signature:___________________________________________________
 
 
 
Please complete the information above and fax to: (703) 243-2593, or mail payment to: National Chiropractic Legal Fund, Post Office Box 75359, Baltimore MD 21275.
 
 
Important Tax Information: ACA Members may deduct as dues and assessments to their Practice Insurance payment to National Legal Action Fund as a business expense; however, ACA recommends that non-members first consult their tax advisors for proper classification.

Frank A. Stiso, DC, FICC, CCSP - ACA Delegate, New Jersey (http://acanj.tripod.com)