Vendor Support Application

MAC Mission

To improve the health and well being of the public by advancing and protecting the practice of chiropractic.

Purpose of the MAC

The purpose of the Michigan Association of Chiropractors is:

To promote the Chiropractic profession as a distinct branch of the healing arts based on the body’s inherent recuperative abilities and the role that vertebral subluxation plays in that process, and
To advocate for Michigan Doctors of Chiropractic, chiropractic patients, and the chiropractic profession to the government, the public, the business community, and the community of third party payers.

This application must be filled out in its entirety for approval of the Board of Directors.

Please fill out the online form below, or click here for a .pdf form, which you may fax back to the MAC at (517) 367-2228.

Date:
	Please Check One: New Member Upgrade Membership
Company Name
Contact Name
Address
City State Zip Code


Phone Numbers: Office
Cell Fax
Email Address Web Site
Company product/service


Date Licensed in Michigan License Number

Please select Vendor Support level
	Vendor Member	$300/year
	Vendor Member Benefit - MAC Membership Fee - $300/year Provide MAC members specific benefit or discount: Describe	$300/year
	Vendor Member Benefit/Non-dues Revenue Program - MAC Membership Fee - $300/year Provide MAC members specific benefit or discount: Describe and Provide residual income to MAC: Describe	$300/year

By filling out this form, I hereby attest to the accuracy of the foregoing information. I understand that my failure to remit dues will result in suspension of all rights and privileges and will result in the loss of membership. Dues are paid in advance.
Dues Payment Options:
I will mail a check for my membership dues to the MAC @ 416 W. Ionia, Lansing, MI 48933
Please set up my account for automatic credit card billing (VISA, Discover, or MasterCard) Please call the MAC office at (800) 949-1401 to provide your Credit Card number.
Please bill me for my membership dues

Please e-mail your company logo for use on the MAC website vendor listings immediately after filling out the application form. We will provide a link to your company website upon Board approval.