Become a CBG Member

CBG CHIROPRACTORS BUYING GROUP, INC.
STRICTLY CONFIDENTIAL

GENERAL MEMBERSHIP FORM

Doctor's Name (required)

Office Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone Number (required)

Fax Number (required)

Email (required)

Office Manager's Name (required)


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?

PediatricSports ChiropracticConsultant (Radiology, Diplomat)Other

If other, please specify

Please name the Chiropractic College that you graduated from (required)

Year of Graduation (required)

Are you involved in any state association or affiliation?
YesNo

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.
YesNo

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

1. Professional Services
AccountingMortgageAcquisition/ selling practiceLegalInsuranceBanking

2. Practice Building
AdvertisingConsultingCoachingWeb Design

3. Career Development
Technique Training and CertificationSports Chiropractic Certification

4. Profit Centers
In office wellness productsSpace advertising in officeWallboardsTelevision Advertising

Would you be interested in a credit line for use toward CBG vendors/suppliers?
YesNo

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

If other, please specify amount

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