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Membership ApplicationName (As on Driver’s License) _________________________________________________________________TBCE License # _______________________
Primary Address ______________________________________________ City_______________________________ ST________ Zip__________
Primary Phone __________________ Mobile __________________ Fax __________________ Email ____________________________________
Practice/Clinic Name ______________________________________________ TX License Date _____/_____ TX Practice Begin Date _____/_____
Practice Specialties ______________________________________________________________________________________________________
Board Specilty Areas _____________________________________________________________________________________________________
Chiropractic School ______________________________________ Graduation Date _____/_____- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Regular 1-Year Membership $50 - Billed Monthly $600 - Billed Annually
Retired/Disabled/Associate Educator $65 - Billed Annually
Out of State (w/ TX License) $65 - Billed Annually
Student Free Free
1st -Year Licensee Free Until Next Annual Billing Cycle Free Until Next Annual Billing Cycle
2nd-Year Licensee $13 - Billed Monthly $150 - Billed Annually
3rd-Year Licensee $25 - Billed Monthly $300 - Billed Annually
CDI Contribution $______ PAC Contribution $______ Litigation Contribution $______
Total Amount to Pay $____________
*Note: Member dues payments and various fund contributions are NOT deductible as charitable contributions for federal income tax purposes, but MAY be deductible as ordinary businessexpenses, subject to IRS restrictions. To the extent that TCA engages in lobbying activities, a portion of dues is NOT deductible as an ordinary and necessary business expense. TCA estimatesthat 31% of your dues are not deductible. Please consult your tax advisor with questions*TCA PAC contributions are NOT deductible. Current laws prohibit contributions to political action cammittees from corporations.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZATION AGREEMENT FOR PREARRANGED PAYMENTS
I (We) authorize Texas Chiropractic Association, herinafter called Company, to initiate debit entries to my credit card or bank account
indicated below for $______ once, or $______ once, and $______ monthly for one year.
Bank Routing Number _________________________________
Bank Account Number _________________________________
Authorized Signature __________________________________
Credit Card Number _________________________________
Credit Card Expiration Date ___________________________
Name on Card ______________________________________
Authorized Signature _________________________________
THIS AUTHORITY MAY BE TERMINATED UPON 30 DAYS’ WRITTEN NOTICE OF ITS TERMINATION TO/FROM ME or TCA
to have the amount of such entry credited to such statement of account or a written notice pertaining to such entry,, the customer shall have sent to BANK or CREDIT CARD a written notice identifying such entry, state in that suchentry was in error and requesting BANK or CREDIT CARD the the amount thereof to such account
e: [email protected] p: (512) 477-9292f: (512) 477-9296
Got a question? Call the TCA office at (512) 477-9292