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.
