American Black Chiropractic Association
Membership Chairperson: Dr. Connie Mitchell
SABCA MEMBERSHIP APPLICATION
Name_____________________________________________Phone_______________________________
Home Address______________________________________City____________St____Zip____________
School Address _______________________________City____________St____Zip____________
Permanent Address _________________________ City____________St____Zip___________
Office Phone __________________Office Fax_______________ Cell Phone________________________
Email Address_____________________________ Website______________________________________
Years in School______________
For Students: School Attending:_________________________ Quarter/Tri_________________________
Professional Memberships: SICA___SACA____Other____________________________________________
Spouse Name_____________________________
Is your spouse interested in the Spouse Auxiliary committee:_____________________________________
Which committee are you interested in becoming a part of:
Membership_____Political______Legal______Scholarship_____Nominating____ Communication____
———————————————————————————————————————————
Type of Membership
New Doctor 1st year Free
SABCA Student – 1 time fee $50.00____ Auxiliary/Spouse $25.00___
Method of Payment
Cash:__________Check________________
Credit Card#_______________________Expiration Date________Name on Card____________________
Address on Card________________________________________________________________________
OR
Mail application with payments to:
ABCA Treasure
PO Box 631725
Irving, TX 75063
