Please fill out this form to opt-out of your free Injury+ listing and advanced training – benefits which were announced by the International Chiropractors Association (ICA) on December 11, 2013. Please understand that your election is permanent. Once submitted, your election to opt-out of the free benefits cannot be reversed. Please allow at least two (2) weeks for us to process your election to opt-out. If you have questions about this form, please feel free to contact Mark Cook of the ICA at 571-765-7557 or Keith Pendleton, JD at 855-224-3295. Thanks! Name* First Last Email Address* This will be your USERNAMEName of Your Company*Company Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company Phone*Confirmation* I understand that my election to opt-out of the free benefits is permanent. Once submitted, my election to opt-out cannot be reversed. I understand that it could take up to two (2) weeks for my election to be processed. If I wish to confirm whether I’ve been removed from the Injury+ listing, I will re-check the Injury+ web site to ensure removal. If I have questions about opting-out, I will contact Mark Cook of the ICA at 571-765-7557 or Keith Pendleton, JD at 855-224-3295.