CERTIFICATE OF MORAL CHARACTER

Note:  The individual completing this form must be a

Licensed Doctor of Chiropractic in good standing

PLEASE PRINT LEGIBLY OR TYPE

APPLICANT’S NAME:________________________________________________

                                           First                                       Last                                    Middle

This certifies that I, the undersigned, am personally and professionally acquainted with ____________________________________________ and know him/her to be of good moral character.  I recommend him/her to the Maryland Board of Examiners as a worthy person to be issued a license to practice chiropractic in the State of Maryland.

ATTESTING DOCTOR’S NAME: _______________________________________________

 MAILING ADDRESS:_________________________________________________________

 ___________________________________________________________________________________

CURRENTLY LICENSED IN ____________  SINCE _______  LICENSE NO.:__________ 

• How long have you known the applicant? ______________________________

• How are you acquainted with the applicant?  Check one:

             ___ professionally             ___ student                 ___ socially                 ___ relative

• How do you know that the applicant is of good moral character?  Explain:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Are you aware of any facts relating to misconduct, administrative, or criminal action against the applicant, or his/her reliance on drugs, alcohol, prescription medication or controlled substances that might affect his/her abilities as a chiropractor?

 ___ YES          ___ NO            (If yes, please describe in detail on a separate attachment.)

 I ATTEST TO THE BEST OF MY KNOWLEDGE, BELIEF AND JUDGMENT THAT THE APPLICANT IS OF SOUND MORAL CHARACTER.

_________________________________________________            ______/______/______

Signature of Attesting Doctor of Chiropractic                                       Date

Revised:  10/2007