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Membership Application Form
PLEASE TYPE OR PRINT NEATLY:


Name: _________________________________[ ] D.C.[ ] Other______________________

Address: ___________________________________________________________________

__________________________________________________________________________

Phone: __________________________________ Fax: ______________________

E-mail: ___________________________________________________________________

[ ] $100 Individual [ ] $50 Student [ ] $75 Senior (65 or older)

[ ] $1000 Lifetime Member [ ] $200 Institutional Member

[ ] Organizational Member (please inquire) [ ] Corporate Member (please inquire)

(All values in US dollars. We welcome members from outside the United States, however international postage costs
are considerably higher than domestic, and the AHC is a small, non-profit organization. Therefore, will Individual
Members please add $10 to the above for shipping costs. Institutions, please add $20, and Lifetime Members please add
$100.)

[ ] Check enclosed

[ ] MasterCard [ ] VISA; # ________________________ Expiration: ___________

MAIL TO:
Executive Director
Association for the History of Chiropractic
4430 8th St.
Rock Island, IL 61201
Email: ahc1895@gmail.com

								
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