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C.C.O. (C)
COLLEGE OF CHIROPRACTIC ORTHOPEDISTS (Canada)
COLLEGE DES CHIROPRATICIENS ORTHOPEDISTES (Canada)
MEMBERSHIP APPLICATION
Name:___________________________________ Date of Birth:______________
Address:_________________________________ City:______________________
Province:_________________________________ Postal Code:_______________
Telephone: Office: (____)________________

    Residence: (____)__________________

 FAX: (____)_______________
Chiropractic College:________________________ Grad year:_______________
Email address: __________________________
Orthopedic Program:
Have you been involved in a post-graduate orthopedic program? YES____ NO____
College:____________________________ Date of Completion:___________

Diplomate of the American Board of Chiropractic Orthopedists
YES____________ NO_________________ Date of Certificate:_______________

Other education and degrees:
________________________________________________________________________
________________________________________________________________________

Other professional association memberships:
________________________________________________________________________
________________________________________________________________________

I hereby apply for membership in the COLLEGE OF CHIROPRACTIC ORTHOPEDISTS (Canada) and have enclosed evidence of my qualifications for the category of FELLOW________, MEMBER_________, ASSOCIATE MEMBER__________. I understand that the failure to remit dues will result in loss of membership and all rights/privileges thereof indicated in the by-laws of the C.C.O.(C)
Signature:________________________________ Date:___________________
Associate Member $75.00
Member $75.00
Fellow $150.00

Make cheques payable to the C.C.O.(C) and send to:
Dr James Sie, D.C. 110-10655 Southport Rd. Calgary, Ab. T2W 4Y1
Tel : (403)-271-7143
Fax : (403) 271-4326
CCO(C) web page URL: theccoc.ca