Regulatory Member Designations

ICRS www.chiroregulation.org

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* Indicates required field

Regulatory Member Organization Name *

Today's Date *

Person designating Regulatory representatives *

Designate ONE person to serve as Regulatory member of the ICRS Board of Directors

Name - Regulatory board member *

First

Last

Choose One *

Dr Prof Mr Ms Mrs

Email *

Choose One *

Same as Appointee to ICRS Board of Directors Different Person

Regulatory Voting Delegate Name - if different *

First

Last

No need to repeat if the same person who serves on the ICRS Board will also be the Voting Delegate

Choose One *

Dr Prof Mr Ms Mrs

Email *

Submit

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icrs@chiroregulation.org

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502-5657 Spring Garden Rd, Box 142
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CANADA