Washington State Chiropractic Association

Doctor of Chiropractic Membership Application

New Member Returning Member
If returning member, approximate years of previous membership

Last Name
First Name
Clinic Name
Address
City
State
Zip
Phone
Fax
Email
Website

Practice Description: In 50 words or less please
describe your practice to potential patients:

Please list any additional services available at your clinic:
Massage Nutrition Pediatrics
Rehab Sports Chiropractic Other(s) - please list below

Top Techniques: Please list the techniques used in your practice:

License Information

WA State License Number
/ / License Date (Month/Day/Year)
Ever practiced elsewhere?
Yes No
Where?
If yes, what year(s)?
Other State(s) currently licensed in
Additional Certs?
(DACS, DABCO, CCSP, etc)
Chiropractic College Attended
/ / Date Graduated (Month/Day/Year)

Name of Sponsoring DC Member?

Additional Questions/Comments?

Membership Dues Rates- Check your category

	Type	Description	Rate
	M1	DC Licensed 0-12 months*	Complimentary
	M2	DC Licensed 13-24 months*	$375/year
	M3	DC Licensed 25-36 months*	$512.50/year
	M4	DC Licensed 37+ months*	$650/year
	MR	DC with WA State license on retired status with the state licensing board	$70/year
	MS	Student currently attending a chiropractic college	$40/year
	MA	Affiliate member (DC Licensed outside Washington State)	$70/year
*Months licensed are calculated based on your first date of licensure in Washington State.

WSCA - 21400 International Boulevard Suite 207 SeaTac, WA 98198

206-878-6055