First Name: *

Last Name:*

Street Address: *

City: *

Zip Code: *

State: *

Office Phone: *

Cell Phone Number: *

Fax:

FL License Number: *

Are you a 1st year FL licensee?
YesNo

Do you have an Out of State License?
YesNo

Date of Birth: *

Email: *

I am a member of :*
FCPACPAABoth (FCPA/CPAA)None (FCPA/CPAA)

Do you believe that chiropractors should have Injectable Nutrition Rights *
YesNoUndecided

I am:*
DCCCPAStudentGuest

Registering for *
February 24th - 26th 24CEUs CE SeminarMembershipCE Seminar & Membership

I have attended an FCPA Seminar in the past *
YesNo

How did you hear about us?:*
By emailReferred by a friendMagazine adPostcardPhone call from FCPA

Are you interested in getting involved in advancing our laws? *
YesNo

I understand that all information regarding the seminar will be sent by email and it is my responsibility to look for and read it.*
Yes

Comments:

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First Name:*

Last Name:*

Name of Chiropractic Office:*

Practice Address:*

City:*

State:*

Zip:*

Office Phone Number:*

Website:*

Email:*

Comments:

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