CBG CHIROPRACTORS BUYING GROUP, INC.

STRICTLY CONFIDENTIAL

GENERAL MEMBERSHIP FORM

Please accept my membership into CBG for one year at no charge (normal yearly fee is $179.00).
This Membership from CBG is valid for one year.

To Receive a Free One Year Membership, you must put your State Association/Affiliation
or Chiropractic College graduated from in the box provided

Please fill out all items that have an asterik (*)
DOCTOR'S NAME *
OFFICE NAME: *
ADDRESS: *
CITY: *          STATE: *        ZIP CODE: *
TELEPHONE:
OFFICE: *                 FAX: *
E-MAIL: *
OFFICE MANAGERS NAME:

CONFIDENTIAL DOCTOR PROFILE: Please fill out only those which you wish to answer:
Other than general practice, are there any other areas of specialty you would like to have listed?


Please name the Chiropratic College that you graduated from?

Name:       Year of Graduation:

Are you involved in any state association or affiliation?    Yes No *

If yes, please list: *
Any other designation or board membership that you would like listed?

Would you like to participate in focus groups for new industry products/services?
(Possible free samples and honoraries paid) No travel required. Yes No

Which of the following areas would you be most interested in saving money (check all that apply)?

1. Professional Services:  
Accounting Legal
Mortgage Insurance
Acquisition/ selling practice Banking

 

2. Practice Building:  
Advertising Coaching
Consulting Web Design

3. Career Development
Technique Training and Certification
Sports Chiropractic Certification


4. Profit Centers:  
In office wellness products Wallboards
Space advertising in office Television Advertising

Would you be interested in a credit line for use toward CBG vendors/suppliers? Yes No

If more than $500 please state the desired amount:
$500
$1,000
$5,000
Other:

If so, please list 2 vendors/ trade references:

1.

2.

Thank you for adding strength to the buying power for members of CBG. Your name below allows you to participate in the CBG programs of your choice and gives CBG your consent to receive faxes, emails and mail sent by or on behalf of CBG.

Name: * Date: *

 
Promotion Code: