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State of Licensure

State of Licensure 1 License Number

Second State of Licensure

State of Licensure 2 License Number

Are you licensed in any other states?

Are you a State Association Member?

State Association

State Association Name

State Association Member Number

Are you an ACA Member?

Are you an ICA Member?

Do you have a state or national chapter membership?

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?

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?

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?

Diplomate/Fellow certificate 3

Other Diplomate/Fellow Status?

State Board Officer?

State Board Office Term Expires (mm/yyyy)

State Association Officer?

State Association Office Term Expires (mm/yyyy)

Other States of Licensure?

What other States are you licensed in?

Other Licenses Held?

* Practice Name

* Address1

Address2

Address3

* City/Locality

State

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

Zip Code

Phone Number 1

Phone Number 2

Home Fax Number

Personal Email Address

Front Desk Email Address

Front Desk / Office Manager

Type of Practice

Public Practice Description

Professional Practice Description

Practice Arrangement

Billing Address
First Name Last Name Address 1 Address 2 City State Postal Code Country Phone

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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) .
We look forward to welcoming you into GoodChiropractic.org.
If you have any questions, please do not hesitate to contact us at
Membership@GoodChiropractic.org

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