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Log in here.Account Information Username Password Confirm Password E-mail Address Confirm E-mail Address Full Name LEAVE THIS BLANK More Information Suffix State of Licensure ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING State of Licensure 1 License Number Second State of Licensure ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING State of Licensure 2 License Number Are you licensed in any other states? Yes No Are you a State Association Member? Yes No State Association ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING State Association Name State Association Member Number Are you an ACA Member? Yes No Are you an ICA Member? Yes No Do you have a state or national chapter membership? Yes No State or National Chapter/Conference Names Other Memberships? Additional Credentials(List, and provide verification information (phone, email)? Diplomate/Fellow Certification Initials 1 Diplomate/Fellow Certification Name 1 Date of Board Certification Credentialing Board 1 Certificate Number Credentialing Board 1 Name Credentialing Board 1 Phone (optional) Credentialing Board 1 Address (optional) Certificate 1 renewed or Maintained within 2 years? Yes No Diplomate/Fellow certificate 1 Diplomate/Fellow Certification Initials 2 Diplomate/Fellow Certification Name 2 Date of Board Certification Credentialing Board 2 Certificate Number Credentialing Board 2 Name Credentialing Board 2 Phone (optional) Credentialing Board 2 Address (optional) Certificate 2 renewed or Maintained within 2 years? Yes No Diplomate/Fellow certificate 2 Diplomate/Fellow Certification Initials 3 Diplomate/Fellow Certification Name 3 Date of Board Certification Credentialing Board 3 Certificate Number Credentialing Board 3 Name Credentialing Board 3 Phone (optional) Credentialing Board 3 Address (optional) Certificate 3 renewed or Maintained within 2 years? Yes No Diplomate/Fellow certificate 3 Other Diplomate/Fellow Status? Yes No State Board Officer? Yes No State Board Office Term Expires (mm/yyyy) State Association Officer? Yes No State Association Office Term Expires (mm/yyyy) Other States of Licensure? Yes No What other States are you licensed in? ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING Other Licenses Held? License 1License2License3 * Practice Name * Address1 Address2 Address3 * City/Locality State ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING Practice Management Number * Practice Appointment Number Fax Number * Direct Email Address Cell Phone Home Address 1 Home Address 2 Home Address 3 City/Locality State ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING Zip Code Phone Number 1 Phone Number 2 Home Fax Number Home Fax Number Personal Email Address Front Desk Email Address Front Desk / Office Manager Type of Practice Wellness/Generalist Specialist/NeuroMusculoSkeletal Mixed Public Practice Description Professional Practice Description Practice Arrangement Solo Group Billing Address First Name Last Name Address 1 Address 2 City State Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands US Armed Forces Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone We Accept Visa, Mastercard, American Express and DiscoverPayment Information Card Type Visa Mastercard American Express Discover Card Number Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 / 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 CVV (what's this?) Discount Code DECLARATION By completing the above form and clicking on "Submit" below, you state: I hereby affirm that I am a Doctor of Chiropractic. I am a member of both my State Chiropractic Association and either the ACA or ICA National Associations, and agree to provide proof upon request of memberships or Diplomate/Fellow status I have described in this application above. I affirm that I am interested in working to benefit the public and the profession, and I am applying for membership in GoodChiropractic.org. I affirm that I will conduct my practice in accordance with the laws and ethical standards of my state, that my license has not been revoked, limited, or suspended, and there are no pending disciplinary actions on my chiropractic license. I agree to advise the Board of GoodChiropractic.org immediately if any of the above information changes. I additionally affirm that the membership information I am submitting is true to the best of my knowledge. I understand that if I falsify any membership information or my credentials, my membership and status will be immediately revoked. I also understand that any use of the trademark GoodChiropractic.org ® is limited only to Members, is subject to written approval and permission, and that Board action will be undertaken to enforce this standard. Thank you for applying to GoodChiropractic.org. We applaud your professional intentions. We certify our members to the public as Committed, Connected, Communicating and Contributing to the profession of Chiropractic. In the next 3 to 5 business days our staff will verify and confirm your above information to the best of our abilities. We will contact you if more information is needed. Upon completion of your Verification Process, you will then receive Login instructions into the unrestricted Member Area, while the site is developing. Until you do receive that confirmation, please do not use the label GoodChiropractic.org (r) . 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