Garden State Chiropractic Society
P.O. Box 831  -  Point Pleasant, NJ  08742

APPLICATION FOR MEMBERSHIP                            
 Print or Type
Full Name______________________________________  Name of Spouse______________________

Office Address________________________________________________________  Zip____________

Home Address________________________________________________________  Zip____________

Telephone (Office)___________________________ (Fax)________________ (Home)______________

All Other Chiropractic Association Memberships_____________________________________________

___________________________________________________________________________________
Other Non-Chiropractic Organizations to Which You Belong____________________________________

___________________________________________________________________________________

Name of GSCS Member Who Sponsored You______________________________________________

Do You Now Use Any Adjunctive Therapies of Modalities?              YES            NO        (Circle One)

Do You Ever Adjust Other Than The Bones Of The Spine Or Its Immediate Articulations?  YES    NO

Are You In Full-Time Practice?               YES               NO

If Not In Practice, Why?________________________________________________________________

List Me In The GSCS Referral Directory?           YES              NO

I hereby apply for membership in the GSCS, and enclosed is a check in the amount of __________.   I understand that my 
application is subject to approval by the Board of Directors and that I will be notified of its actions. In applying for membership, 
I agree to abide by the Charter Provisions, Constitution, By-Laws and all amendments and Regulations of the Garden State 
Chiropractic Society. I  also understand that failure to remit dues when due, or non-compliance with the aforesaid rules, 
upon action of the Board of Directors, may result in loss of membership and all rights and privileges thereof.

Signature of Applicant___________________________________________   Date________________


PLEASE CHECK TYPE OF MEMBERSHIP
____________   General Member:            $300 Annually  ($75 Initial,  $75 Quaterly)
____________   1st Year Out of School:   $100 Annually  ($25 Initial,  $25 Quaterly)
____________   Associate Member:         $ 25 Annually  
____________   Student Member:            Complimentary
                        Name of School:___________________  Est. Graduation Date:________________
                        (Dues Check Must Accompany Application)
                        Make Checks Payable to:
                        GSCS, c/o  Dr. Thomas S. Catarella, 245 Avenel Street, Avenel, NJ 07001
____________________________________________________________________________________
FOR OFFICIAL USE ONLY:
Interview Date:___________ Conducted By:__________________
Accept:     YES        NO
Phone Chain:

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Last Updated:  25 September 2002 12:25 AM