GCC Membership Application

GCC Membership Application

This is a secure form. Please fill in form below.

Doctor Information

Last Name
First Name
Middle Initial
Email Address

Clinic Information

Clinic Name
Office Street Address
City (Office)
County
State
Zip
Office Phone
Office Fax
Cell Phone
Web Address

Personal Information (Optional)

Home Address
Home City
State
Zip
Home Phone

Educational & Practice Information

Chiropractic College Graduated url('http
Year of Graduatio
Years In Practice
Other Degrees other than DC

Areas of Interest

Who Recommended You for GCC Membership
Areas of Special Interest: (Check all that apply)
Public Speaking	Research
Public Relations	Teaching
Insurance Relations	Other

Membership Categories

(Please Select Appropriate category)

Select	Category	Fee
	First 12 months after graduation. (Non-voting)	Free
	First Year Licensed (Any state)	$125
	Second Year Licensed	$200
	Licensed Three or More Years (Annually)	$400
	Licensed Three or More Years (Quarterly)	Per Quarter $125
	Licensed Three or More Years (Monthly)	Per Month $50
	Associate Member (DC Spouse in Same Office)	$200
	Full Time Faculty (Non Practicing Only)	~~$200~~ $100 ($100 Instant Rebate)
	Auxiliary (Out of GA DC - Includes Convention & Voting)	$200
	Auxiliary (Out of GA DC - non voting, no convention)	$40
	Student (One Time Fee While in DC School)	$40
	Affiliate (CA, CT, non DC Spouse of GCC member - non voting)	$40
	Retired & Over 65	$50
	Over age 65 and still in practice	$200

Payment

Method of Payment
Pay by Check
Terms of Payment
Monthly	Quarterly	Annually
Total dues amount selected from membership category above.

Comments, Questions, Areas of Concern.

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