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Council on Forensic Sciences

College on Forensic Sciences - Membership

Student Membership Application Form

Name:

College on Forensic Sciences - Membership

Home address:

College on Forensic Sciences - Membership

City:

College on Forensic Sciences - Membership

State:

College on Forensic Sciences - Membership

Zip:

College on Forensic Sciences - Membership

Mailing Address:

College on Forensic Sciences - Membership

(if different from above)

City:

College on Forensic Sciences - Membership

State:

College on Forensic Sciences - Membership

Zip:

College on Forensic Sciences - Membership

Email:

College on Forensic Sciences - Membership

Phone:

College on Forensic Sciences - Membership

Phone (Cell):

College on Forensic Sciences - Membership

Personal Information

Social Security #:

College on Forensic Sciences - Membership

Date of Birth:

College on Forensic Sciences - Membership

(mm/dd/yyyy)

Professional College:

College on Forensic Sciences - Membership
 

Degree(s)/Institution:

College on Forensic Sciences - Membership

Date of Graduation:

College on Forensic Sciences - Membership

(mm/dd/yyyy)

State(s) Licensure:

College on Forensic Sciences - Membership College on Forensic Sciences - Membership College on Forensic Sciences - Membership

License Number(s):

College on Forensic Sciences - Membership College on Forensic Sciences - Membership College on Forensic Sciences - Membership
 

Membership Recommended by:

College on Forensic Sciences - Membership

Requested Documents to be forwarded:

College on Forensic Sciences - MembershipCompleted Application

College on Forensic Sciences - MembershipCompleted Consent & Release

College on Forensic Sciences - MembershipSACA membership verified by email or fax

College on Forensic Sciences - MembershipCopy of Driver's license


Consent & Release

By applying for membership, I agree to the following:
 

1.

To immediately notify - in writing - the CFS of any changes made or proposed in the status of education, to my home and/or mailing address, or any other demographic information.

2.

To hold harmless and release from any and all liability, the ACA, the CFS, its authorized representative(s), and any third parties who, in good faith and without malice, review, act or provide information regarding my background, experience, educational competence, professional student ethics, health status, and/or other qualifications for application approval.

3.

To abide by the terms of the CFS bylaws, Guideline of Conduct, and Rules and Regulations, as amended and as related to the policies and procedures of the CFS and its members.

4.

To authorize the CFS or its representative(s) to make inquiry, perform a background check, to consult with prior associates or others who may have information regarding my background, educational competence, professional student ethics, health status, and/or other qualifications that may be material to this membership.

5.

To attest to the correctness and completeness of all information provided in this application, and to further acknowledge that any material, misstatement, or intentional omission of information from this application constitutes grounds for denial of membership and/or summary dismissal.

* By submitting this application or my signature below(if printed copy), I certify that I have read and understand the above-captioned CFS Consent & Release and agree to comply with same.

I Agree

College on Forensic Sciences - Membership

I Disagree

College on Forensic Sciences - Membership

Signature:

College on Forensic Sciences - Membership

Date:

College on Forensic Sciences - Membership

Send application to

Council on Forensic Sciences
Clayton W. Hopkins, DC, DABFP
6231 66th Street North
Pinellas Park, FL 33781
Phone: 727-544-3330 | Fax: 727-544-3221


Please note that membership in the Council on Forensic Sciences is contingent upon current membership in the Student American Chiropractic Association (SACA).

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