Council on Forensic Sciences

Student Membership Application Form

Name:
Home address:

City:

State:

Zip:

Mailing Address:
	(if different from above)

City:

State:

Zip:

Email:
Phone:
Phone (Cell):

Personal Information

Social Security #:		Date of Birth:
			(mm/dd/yyyy)

Professional College:

Degree(s)/Institution:		Date of Graduation:
			(mm/dd/yyyy)

State(s) Licensure:
License Number(s):

Membership Recommended by:

Requested Documents to be forwarded:

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
I Disagree

Signature:

Date:

Send application to

Council on Forensic Sciences
Attn.:  Dr Leanne Cupon
1305 Hembree Road Suite 203
Roswell, GA 30076

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

Apply for membership online Click here

Download Student ACA Membership Application Click here