Membership Registration OLD FORM

Membership and Certification Testing Application Form
Please complete form below to sign up. Once the form has been received, it will be reviewed for accuracy and you will be contacted as soon as possible. At the current time, we are conducting testing procedures during the last day of the last scheduled module of the Animal Chiropractic or VSMT program of those schools that requests for us to provide the certificate test.

Please choose from the following options:*

I would like to RENEW my membershipI would like a NEW membership

Full Name*

First NameLast Name

Professional Degree:*

Business Name:

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Website Address:

Business Phone Number:

Fax Number:

Cellular Number:

Professional School:*

Personal Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone Number:*

Professional Degree:*

Date of Graduation:*

State/Provincial License Number*

Animal Chiropractic Training School or Program*

By entering your name below, you are agreeing that all of the information provided in this form is accurate and correct.

Full Name*

First NameLast Name

Please Note: If completion of this testing is unsuccessful, you will be refunded $100USD or $110Cdn or 75 euros which represents the Membership portion. All additional funds are non-refundable

Please select from the following options:*

Canadian Membership Registration$325.00

U.S. Membership Registration$325.00

European Registration$325.00

Canadian/USA Renewal$75.00

European Renewal$75.00