Download a Membership Application

By joining The Chiropractic Trust, you are welcomed into a group who will vouch for you, converse with you and provide for you all things straight chiropractic. Belong to The Chiropractic Trust and you’ll have support for what you do all the time.

To join The Chiropractic Trust, simply select the application that pertains to you below, fill it out and then email it to The Chiropractic Trust, or mail it to:

Mark J Romano, DC
171-C East Oxford St
Pontotoc, MS 38863

To apply, simply complete The Chiropractic Trust Membership Application. Once your application is received we will notify you.

 

PRACTICING CHIROPRACTORS ONLY


Solo Practice    Partnership    Group Practice?

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

STUDENTS ONLY


Yes    No

Yes    No

CHIROPRACTIC ASSISTANTS ONLY


Yes    No

Terms of Acceptance & Commitment to The Chiropractic Trust

I, , have read, understand and agree that I have completed the above application correctly and truthfully, to the best of my knowledge.

I understand and agree that if accepted for membership, The Chiropractic Trust is primarily directed at preserving, protecting and promoting the rights and practices of the non-therapeutic, straight chiropractor without compromise and that my participation in this organization, or any of its functions, is completely and strictly voluntary and that I may withdraw as a member at any time for any reason.

I understand and agree to practice in accordance with the Constitution and By-Laws of The Chiropractic Trust to the best of my ability and I acknowledge that there are certain rights, benefits and privileges from participating in this organization and those same rights, benefits and privileges may only be received by my adherence to the same Constitution and By-Laws. I understand that should I no longer practice in a manner consistent with non-therapeutic, 171-C East Oxford St • Pontotoc, MS, 38863 662.489.3322 TheChiropracticTrust.com straight chiropractic or practice in direct violation of the Constitution and/or By-Laws of The Chiropractic Trust, as determined by the board, my membership will be subject to cancellation or may be placed in an alternative and more appropriate membership classification.

I understand and agree that as part of the rights, benefits and privileges afforded to me by The Chiropractic Trust, I may be privy to certain information that is proprietary in nature, copyrighted or otherwise protected, such as but not limited to policies, procedures, seminar materials, objectives, goals and professional positions and standards designed for or by The Chiropractic Trust and used to fulfill its missions and objectives. I agree to keep this information confidential when necessary by not sharing this information with other competing entities, chiropractic or otherwise, whether or not it is for financial gain.

I understand and agree to act and practice as a professional and conduct myself in a respectful, moral and ethical manner that is representative of the non-therapeutic, straight chiropractor and of The Chiropractic Trust.

Membership Payment Authorization Form
Please Choose A Membership Option and Complete Form Below



Monthly ($35/month)

Yearly ($50/year)

Free Until Graduation
Graduation Date: School:

(CHOOSE ONE)

By choosing one of the monthly recurring payment options above, I, (print name) , hereby authorize The Chiropractic Trust to bill the credit/debit card or checking account listed hereon for $ as indicated by my membership option above, on today’s date and each month hereafter and agree to perform the obligations set forth by the credit/debit card issuer and the terms of the membership agreement. I further authorize monthly payments to continue indefinitely or until I notify The Chiropractic Trust in writing to cancel the membership. (initial)

For CA Only

By choosing one of the annual payment options above, I, (print name) , hereby authorize The Chiropractic Trust to bill the checking account listed below for the amount indicated by my membership option above on today’s date and each year thereafter on the anniversary date of my membership join date and agree to the terms of the membership agreement. I further authorize annual payments to continue indefinitely or until I notify The Chiropractic Trust in writing to cancel the membership. (initial)


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I agree to notify the business in writing of any changes in my account information or termination of this authorization 30 days prior to the next due date of the charges. For ACH debits to my checking/savings account, I understand that because this is an electronic transaction, these funds may be withdrawn from my account each month as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the company’s recurring billing with my bank or credit card company; so long as the transaction corresponds to the terms indicated in this agreement.

Information below is encrypted, stored and protected offsite. This portion will be shredded after input.

Checking/Savings Account (ACH)

Checking, Savings

Checking/Savings Account (ACH)