In order to report your hours accurately and to receive confirmation from the University, please be sure that your address is current and can be used as the standard USPS format. Please refrain from using all caps when filling out the form.
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
Do you require ACBN-CBCN Credits? Yes (There is a $100 additional fee for ACBN CBCN credits)No
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
Registering for * February 18th - 20th 26CEUs CE SeminarMembership
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:
First Name:*
Name of Chiropractic Office:*
Practice Address:*
City:*
State:*
Zip:*
Office Phone Number:*
Website:*
Email:*
