UNITED STATES SPORTS CHIROPRACTIC FEDERATION
APPLICATION FORM

Please Print

Name _____________________________________________ Date_______________
             Last                           First                        Middle Initial

Office Address Street _________________________ City_______________ State____
 

Zip Code __________ Office Telephone ______________ Office Fax ______________
 

E-mail address ______________________________________________
 

Other Telephone Numbers ____________________________________________
 

Degree(s) Held ______________________________________________________
 

I currently belong to the following organization(s):  Check all that apply.

o ACA Sports Council o ICA Sports Council o ProSport  o CEPAo FICS o ACSM

Other _________________________________________________________
 

Specialty Certifications ____________________________________________
 

Current Malpractice Carrier and Exp. Date _________________________________

____________________________________________________________________

The dues are $75.00 per year.  Should you have any questions, please call Monty Wilburn, Treasurer, USSCF at 970-224-2282. Please make checks payable to United States Sport Chiropractic Federation. 

Mail your payment of $75.ooand application (check made out to USSCF) to:

USSCF
c/o The Foundation for Chiropractic Education and Research ( FCER)

P.O. Box 400,

Norwalk, IA 50211-0400

Telephone: 800-622-6309

Fax: 515-981-9427

Contact: Cheryl Huff cheryl@fcer.org