ACA International Membership Application Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Non-Binary

Undisclosed

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please provide details of your registration body reference number.(Required)

Please provide details of local association membership.(Required)

Please provide details of your local association membership number.(Required)

Would you like to join an Australasian Institute of Chiropractic Education (AICE) Clinical Practice Group?

Chiropractic Neurorehabilitation

Chiropractic Paediatrics

Chiropractic Sports & Exercise

Chiropractic Wellbeing & Lifestyle Medicine

An additional fee applies ($120.00 AUD pro rata)

Primary Chiropractic Qualification(Required)

Graduating Institution(Required)

Year of Graduation(Required)

Please list further qualification here, if applicable.

Have you had or are you aware of any malpractice claims against you?(Required)

Yes

If yes, please provide details.

Have you ever been convicted of a criminal offence?(Required)

Yes

If yes, please provide details.

Join the peak body representing
chiropractors