Quantity desired @ $ = SubTotal $ + shipping = Total $

Target date for delivery

METHOD OF PAYMENT:

Card Number    Exp Month Mn 1 2 3 4 5 6 7 8 9 10 11 12    Exp Year Year 2003 2004 2005 2006 2007 2008 2009 2010 2012 2013 2011

This Chiro CD features the award winning video, “Doctor of Chiropractic,” and is good for educating legislators, patients, & other health care professionals.

Use the and the buttons to process this form online.
 The form data is emailed to the KCA office staff, who will contact you to confirm the order information.

Otherwise, you may print this form and mail or fax it to:

Kansas Chiropractic Association
1334 S. Topeka Blvd.
Topeka, KS 66612
785-233-0697 (phone)
785-1833 (fax)

Note:  There is no data from this form kept on the internet server.  This form submits information by an email attachment sent from your computer to the KCA office.  The security level of the information is the same as any other email message you send.  If you are not comfortable sending the information in this form through email, then you may print the form, complete it, and then fax or mail it to the KCA office.