Apply

These forms may be:

Faxed to 401-847-1449

Emailed to director@richiro.org

or Mailed to: CSRI, 1272 E. Main Rd, Bldg #2, Middletown, RI  02842

1. Member Application    

List Information as you would like it to appear on the CSRI website.

Name: __________________________________________ Year of Graduation: ____________________

Office Name: _____________________________________ Office Phone: _________________________

Office Address: _________________________________________________________Zip ____________

Office Email: ____________________________________________ List email on website:  Yes   No

Personal Email: ________________________________________________________________

Office Web URL: _________________________________________ List URL on website:    Yes   No

Office fax: ____________________________ College of Graduation: _____________________________

Licensed to practice in RI?   Yes   No Year of License _________  Year of Graduation _____________

List other states licensed to practice ________________________________________________________

List other schools of healing science ________________________________________________________

List areas of specialty ___________________________________________________________________

Home Address _________________________________________________________________________

Home Phone ____________________________ Send invoices to:    Office    Home    Email

Provide the name and phone for two chiropractors as references:________________________________

_____________________________________________________________________________________

Has there ever been a criminal or civil action brought against you? ______  If yes, explain below.

Are there any suits or prosecutions pending or threatening at this time? ____ If yes, explain below.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________                                                                                                                                                                         

I, the undersigned, hereby apply for membership in the Chiropractic Society of Rhode Island. To receive benefits accruing to such membership, I hereby agree to abide by the CSRI constitution, bylaws and all rules and regulations thereafter adopted. In addition,     

I will make a good faith effort to pay dues in a timely fashion and participate in CSRI events.

Signature _________________________________________________  Date ______________________

2. Credit Card Information

Cardholder’s Name as it appears on card

_______________________________________________________________________

Cardholder’s Address

_______________________________________________________________________

City _________________________________State ___________ Zip _______________

Credit Card Type:    MasterCard     Visa    AMEX

Credit Card Number: ______________________________________________________

Expiration Date ___________________  Security Code __________________________

I hereby authorized the CSRI to charge my credit card for dues and other charges as

indicated below:                               

Dues:

  In full for the balance of my account

  In four equal installments

  In equal monthly installments

Signature _______________________________________________________________