These forms may be:
Faxed to 401-847-1449
Emailed to firstname.lastname@example.org
or Mailed to: CSRI, 1272 E. Main Rd, Bldg #2, Middletown, RI 02842
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 ______________________
(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
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
In full for the balance of my account
In four equal installments
In equal monthly installments