Representatives of Delta Sigma Chi International Chiropractic Fraternity
Representatives are required to attend an annual meeting and to be the contact person in their region, state or province for newly graduating brothers.  Consider the possibilities of becoming a network of support for the founding principles of chiropractic and the practice success of our brothers.  You will be making a difference in our fraternity and in chiropractic by choosing to serve as a representative.
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State / Province / Region to Be Represented *
Your Last Name *
Your First Name *
Your Brother Name *
Your Chapter *
Your Graduation Year *
Your Personal Email *
Your Mobile Phone # *
Your Facebook Page *
Practice Name *
Practice Phone *
Practice Email *
Practice Street Address *
City *
State / Province / Territory *
Postal Code *
Country *
Practice Website *
Your State / Province Board Information : Contact Person, Telephone #, Mailing Address *
Special Requirements to Practice in Your State / Province *
To which National or International Chiropractic Associations do you belong? *
Leadership Positions you have held or are holding: *
To which State Associations do you belong? *
Leadership Positions you have held or are holding: *
Any other Chiropractic Organizations to which you belong? *
Leadership Positions you have held or are holding: *
Community Organizations in which you are Involved: *
Leadership Positions you have held or are holding: *
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