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Location

 

1272 W Main Rd,
Middletown, RI 02842
(401) 207-0700

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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

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

(Fill this form out if you wish to pay your dues by credit card,
either monthly, quarterly or in full)
 

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 _______________________________________________________________