An organization of Chiropractic Physicians and Neurosurgeons dedicated to
conservative and cooperative spinecare.
Office Phone:
Home Phone:
Fax Number:
Practice Name:
Title:
Web Site http://
How Did You hear about The AASP:
Membership Type:
Method of Contact:
Email:
Please Enter (Credit Card Information) and (Billing Options)
Card Number:
Name on Card:
Expiration Date:
/
Card Type:
Billing Address:
City:
State/Province:
Zip:
Country:
Please Choose Credit Card Billing Options
$250 (1 Year Membership Special with Frame)
Broadway Frame
Classic Frame
Grandeur Frame
Auto Renew AASP Membership
Do not auto renew AASP Membership
**Auto Renewal - Selecting auto renewal guarantees that your membership will not lapse and your right to use reprinted material is not violated. At the end of the membership period your membership will automatically be renewed and your credit card charged accordingly.
Auto renewal also guarantees uninterruption of services with an AASP website and directory listing.
**Due to the exponential growth of the AASP, we have placed a priority on electronic processing which is more efficient and ensures a more accurate database.
I, the undersigned, hereby make voluntary application to the American Academy of Spine Physicians (AASP). I understand and agree that in making application to, and/or being accepted as a member of the AASP, that I am a licensed neurosurgeon or chiropractic physician and that my professional practice as such involves the evaluation and care of patients with spinal disorders.
I further agree that I will honor and comply with all local, state and federal laws and regulations which apply to me as a person and as a professional, and that I will conduct myself in a manner consistent with the highest level of professional ethics. I agree to be bound by the ethical guidelines of the AASP found in the AASP Documentation Library.
I affirm that the information that I have provided to the AASP is true and accurate. I agree to function within the limits of my training, competence, and professional license. I further understand and agree that the AASP and its affiliates assume no responsibility for any of my activities, actions or representations.
