| 2008
MEMBERSHIP DUES |
| |
| |
| Membership |
(All
dues are calendar year.) |
TOTAL |
| Regular
Member: |
$500
annually, to be paid
_____ monthly _____annually |
$_____ |
$250 annually
for Doctors working part time due to impairment or illness,
confirmed by physician
_____ monthly _____annually
$250 annually for previously licensed DC NEW to NM
____monthly _____annually
|
$_____
$_____ |
| New
Licensee: |
$0.00 annually
(within 1st 12 months), $100 annually (within 2nd 12 months),
& $200 annually (within 3rd 12 months) |
$_____ |
| Out-of-State
Doctor: |
$150 annually
(licensed DC practicing outside NM) |
$_____ |
| Student:
|
$25 annually |
$_____ |
| Professional
Associates: |
$100 annually
(non-DC business or individual) $_____ |
$_____ |
| Honorary
Member: |
Exempt from
dues (retired and age 60+ or disabled) |
$_____ |
| Early
Renewal: |
If paying
by December 31, deduct 10% |
$_____ |
| CONTRIBUTIONS: |
| PAC: |
Non-deductible
political campaign contribution fund |
$_____ |
| President's
Circle: |
Non-deductible
legislative expense & lobbyist fund
Member: $1,000 or more;
Associate: $1-$999 |
$_____
|
| Scholarship
Fund: |
Contribute
to helping new Doctors of Chiropractic |
$_____ |
| PR
Media Fund: |
Making Chiropractic
visible throughout NM |
$_____ |
| |
|
|
| |
I am applying as a _________________________ member. Enclosed
is |
$_____ |
I am paying by Visa # _____________________________Expiration
Date: ______ |
I am paying by MC# ______________________________
Expiration Date: ______ |
| |
I
am paying by Discover #_________________________ Expiration
Date: ______ |
PLEASE REFER A COLLEAGUE:_________________________________________ |
| |
PLEASE
MAKE OUT SEPARATE CHECKS FOR MEMBERSHIP, PAC AND PRESIDENT'S
CIRCLE.
Please mail application with credit card information, check
or money order to: NMCA, P. O. Box 21100, Albuquerque, NM 87154
|
