4201 Patterson Avenue, Baltimore, MD 21215-2299 410-764-4726 FAX 410-358-1879
APPLICATION TO PRACTICE CHIROPRACTIC
ALL QUESTIONS BELOW MUST BE ANSWERED LEGIBLY. THE FILING OF THIS APPLICATION
DOES NOT GRANT ANY PRIVILEGE TO OPEN AN OFFICE OR TO ENGAGE IN THE PRACTICE
OF CHIROPRACTIC IN MARYLAND. ALL APPLICATIONS ARE SUBJECT TO INVESTIGATION
AND VERIFICATION OF PERSONAL AND PROFESSIONAL HISTORY, AND DOCUMENTATION.
_______________________________
I HEREBY MAKE APPLICATION for a license to practice chiropractic in accordance with the Chiropractic Practice Act (MD H.O. Article, Section 3-101, et seq.). I herewith enclose the application fee of $150.00 and the examination fee of $300.00. ALL FEES ARE NON-REFUNDABLE. Submit only bank drafts, certified checks, or money orders, made payable to: “The Maryland Board of Chiropractic Examiners.” Cash, personal checks, or credit cards are not accepted.
ALL QUESTIONS BELOW MUST BE ANSWERED COMPLETELY AND LEGIBLY
1. Full Name: _____________________________________________________________________________________
Last First Middle Maiden
2. Mailing Address: ___________________________________________________________________
City: ______________________________________ State: _____________ Zip Code: ________
E-Mail Address: _____________________________ Telephone No.: (______) ________________
3. Date of Birth: ____/____/____ Current Age: _______ Place of Birth: _________________________
4. Social Security Number: _____________________________________________________________
5. Graduate of what High School: ________________________________________________________
Location: _________________________________________________________________________
6. Graduate of what Undergraduate College: _______________________________________________
College Address: ___________________________________________________________________
Degree Received: _________________________ Date of Graduation: ______________________
7. Graduate of what Chiropractic College: _________________________________________________
Chiropractic College Address: ________________________________________________________
Degree Received: ________________________ Date Degree Received: ___________________
8. If you attended more than one Chiropractic College, list below with the dates of attendance:
a. ________________________________________________________ Date: _________________
b. ________________________________________________________ Date: _________________
9. Have you ever been expelled or suspended from any chiropractic college?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
10. Has any federal, state or municipal licensing, certification or disciplinary Board or comparable body in
the Armed Forces taken any action against any license, certification or registration in your name?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
11. Have you ever applied for any license, certificate, application, or diploma to be issued by a
professional or governmental agency or board, and been denied or refused?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
12. Have you ever been arrested, pled guilty, nolo contendere, no contest, or have been convicted or
received probation before judgment for any criminal act, felony or misdemeanor (to include DUI or
DWI)?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
13. Are there any pending investigations, charges, complaints or allegations pending against any of your
licenses, certifications or registrations?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
14. Has any hospital, HMO, or related health care entity or organization or employer denied you
privileges or employment, or denied application for employment, or did not renew your contract for a
reason related to your practice?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
15. Have you ever been addicted or dependant on alcohol, or any drug or controlled substance? Have
you ever used an illegal drug or controlled substance or misused any prescription medication?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
16. Have you ever held a license to practice chiropractic in any state or foreign jurisdiction?
YES _______ NO _______ (If yes, explain below when and where.)
________________________________________________________________________________
17. Has a malpractice civil suit or action ever been filed against you? Has a claim been made against
you? Has a settlement or award been made against you relating to you or your practice?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
18. Have you ever been separated from any service of the U.S. Government for less than honorable
reasons or for administrative reasons other than an honorable or administrative under honorable
conditions discharge?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
19. Have you had a physical or mental illness, injury or disability that impairs your ability to practice?
YES _______ NO _______ (If yes, explain in detail on a separate sheet.)
20. Please account for your last five years, listing education, occupation(s), achievements,
residence(s), etc. (Attach a separate sheet, if necessary.)
________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
YOU MUST PROVIDE AN INKED
PRINT OF THE RIGHT THUMB
IN THE ABOVE BOX.
CERTIFICATE OF APPLICANT
I HEREBY CERTIFY that I am the applicant cited in the foregoing application. I further certify that the photographs herein attached are a true likeness of me, taken on or about the ___________ day of ________________ , _______.
I further attest to the following:
HEIGHT: _________ WEIGHT: _________ HAIR COLOR: _________ EYE COLOR: _________
OTHER PHYSICAL IDENTIFYING MARKS: ________________________________________________
State of: ________________________________________________________
County of: ________________________________________________________
______________________________________________ being duly sworn states that he/she is the person referred to in the foregoing Application for License to Practice Chiropractic in Maryland, and that he/she has carefully read and fully understands this Affidavit, and the statements herein are true in every respect.
__________________________________________________________________
Applicant’s Signature in Full
Signed and sworn to before me this _______day of ______________ , __________ SEAL
__________________________________________________________________
Notary Public Signature
My Commission Expires: _________________________________ , ___________
10/2007
CERTIFICATE OF MORAL CHARACTER REQUIREMENT
You must list the full names and addresses of two (2) licensed doctors of chiropractic who can attest to your moral character. The two chiropractors listed must complete, sign and return to you the moral character forms. You must submit the completed forms with this application, along with all applicable fees.
1. NAME: _______________________________________________________________________________
ADDRESS: _______________________________________________________________________________
2. NAME: _______________________________________________________________________________
ADDRESS: _______________________________________________________________________________
PLEASE NOTE THE FOLLOWING:
YOU ARE REMINDED THAT COMPLETING THIS FORM AND PROVIDING ALL DATA AND FEES DOES NOT GUARANTEE THE ISSUANCE OF A LICENSE TO PRACTICE CHIROPRACTIC. SHOULD A LICENSE BE APPROVED, YOU MUST WAIT UNTIL ACTUALLY RECEIVING THE PRINTED LICENSE BEFORE PRACTICING CHIROPRACTIC IN MARYLAND.
YOU ARE ALSO REMINDED THAT ALL TRANSCRIPTS, DIPLOMAS AND NBCE SCORES MUST BE SENT UNDER SEAL DIRECTLY TO THE BOARD FROM THE RESPECTIVE REGISTRAR OR RECORD CUSTODIAN OF THE INSTITUTION IN QUESTION. THE BOARD WILL NOT ACCEPT ANY SUCH DOCUMENTATION SUBMITTED FROM ANY OTHER SOURCE OR HAND-DELIVERED BY THE APPLICANT. THERE ARE NO EXCEPTIONS, EXEMPTIONS, OR WAIVERS TO THIS REQUIREMENT.
____________ooOoo____________
THANK YOU FOR YOUR INTEREST IN PRACTICING CHIROPRACTIC IN MARYLAND.
10/2007