INTERNATIONAL COLLEGE OF CHIROPRACTORS, INC.

Office of the Interim Secretary
Richard G. Brassard, D.C., FICC, FACC
Phone: 281-998-3492

 

NOMINATION TO FELLOWSHIP

 

I hereby nominate Dr. (Please use name desired on certificate)

Address:

City: State: Zip Code: Country:

for the Degree of Fellow of the
International College of Chiropractors, Inc.

DATE OF BIRTH: Month: Day: Year:

Dr. has rendered valiant service to our Beloved Profession as follows:

MUST BELONG TO AMERICAN CHIROPRACTIC ASSOCIATION, CANADIAN CHIROPRATIC ASSOCIATION, AUSTRALIAN CHIROPRACTIC ASSOCIATION, JAPAN CHIROPRACTIC ASSOCIATION, ETC. AND MUST SUBMIT A CURRICULUM VITAE

It is understood that I shall not disclose this nomination to nominee or others until I am advised of election.
(Be certain nominee is well qualified.)

Dr. Fellow

Address:
NOTE: Must provide actual address. PO Box numbers NOT acceptable

City: State: Zip Code: Country:

 

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