You are now one step closer to getting MORE Credibility and Authority by becoming the 'GO-TO' DOC in your community by applying to become a Chiropractic Media Ambassadors

Initial Application

Fully Complete this Application for Consideration in the Program

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* 1. Address

Drs. Name *

Practice Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 2. How many years have you been in practice?

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* 3. Overall, how would you rate your experience level working in various forms of media?

	Very Comfortable	Moderately Comfortable	Somewhat Comfortable	Dabbled	No experience
Social Media	Social Media Very Comfortable	Social Media Moderately Comfortable	Social Media Somewhat Comfortable	Social Media Dabbled	Social Media No experience
Print	Print Very Comfortable	Print Moderately Comfortable	Print Somewhat Comfortable	Print Dabbled	Print No experience
Television	Television Very Comfortable	Television Moderately Comfortable	Television Somewhat Comfortable	Television Dabbled	Television No experience
Radio	Radio Very Comfortable	Radio Moderately Comfortable	Radio Somewhat Comfortable	Radio Dabbled	Radio No experience
Podcast	Podcast Very Comfortable	Podcast Moderately Comfortable	Podcast Somewhat Comfortable	Podcast Dabbled	Podcast No experience

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* 4. Give us a brief summary of your media experience.... (if applicable)

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* 5. As a Chiropractic Media Ambassador, you will be learning to work in all kinds of media. Tell us your interest level for mastering each of these?

	Most Interested	Very Interested	Moderately Interested	Somewhat Interested	Not Sure
Social Media	Social Media Most Interested	Social Media Very Interested	Social Media Moderately Interested	Social Media Somewhat Interested	Social Media Not Sure
Print	Print Most Interested	Print Very Interested	Print Moderately Interested	Print Somewhat Interested	Print Not Sure
Television	Television Most Interested	Television Very Interested	Television Moderately Interested	Television Somewhat Interested	Television Not Sure
Radio	Radio Most Interested	Radio Very Interested	Radio Moderately Interested	Radio Somewhat Interested	Radio Not Sure
Podcast	Podcast Most Interested	Podcast Very Interested	Podcast Moderately Interested	Podcast Somewhat Interested	Podcast Not Sure

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* 6. What are your goals? What do you hope to accomplish with your increased knowledge & skills as a Chiropractic Media Ambassador?

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* 7. Why do you feel that you make a good candidate for the Chiropractic Media Ambassadors program?