Maryland Board of Chiropractic Examiners

4201 Patterson Avenue  · Baltimore, Maryland  21215 ·410-764-4726 · 410-358-1879 (fax)

 

APPLICATION FOR LICENSURE BY WAIVER OF REQUIREMENTS FOR VISITING CHIROPRACTOR (COMAR 10.43.05D)

 

  • Licensure under this provision is limited to 30 days per calendar year, and solely with and during the organization’s/event’s visit
  • Application/licensure fee is $650.00
  • Applicant must hold a current CPR certification at the provider level
  • Applicant must provide a written certification from his/her State Board verifying status of practice in good standing
  • Applicant must complete and submit this form in its entirety


I HEREBY MAKE APPLICATION for a license to practice Chiropractic in accordance with the Chiropractic Practice Act, and the rules and regulations of the Board of Chiropractic Examiners of the State of Maryland, and herewith enclose the Application fee of $650.00. (Personal checks not accepted. Remit by Bank Draft, Certified Check, Money Order.) Make Checks Payable to MARYLAND STATE BOARD OF CHIROPRACTIC EXAMINERS. All Application Fees are NON-REFUNDABLE



         APPLICANT NAME: ______________________________________________________________ 

ADDRESS: _____________________________________________________________________

STATE(S) IN WHICH CURRENTLY LICENSED:  _______________________________________

 LICENSE NUMBER(S): ________________________    STATUS:  ACTIVE ____  INACTIVE ____

 HOW LONG HAVE YOU PRACTICED?  ______________________________________________

 LIST ANY SPECIALTIES OR CERTIFICATIONS YOU HOLD: _____________________________

 ______________________________________________________________________________

 

 NAME, MAILING ADDRESS, AND PHONE NUMBER OF THE VISITING ORGANIZATION/ EVENT WITH WHICH AFFILIATED:

 ________________________________________________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 

 

NAME OF INDIVIDUAL AND TITLE FROM ORGANIZATION/EVENT THE BOARD MAY CONTACT AS A REFERENCE:

 ________________________________________________________________________

 YOUR TITLE AND/OR AFFILIATION WITH ORGANIZATION/EVENT:

 ________________________________________________________________________

 

DATES WHICH PRACTICE WITH ORGANIZATION/EVENT IS ANTICIPATED IN THE STATE OF MARYLAND:

 

            __________________________     TO    _________________________

 

 

PLEASE ANSWER YES OR NO.  ANY YES RESPONSES MUST BE

ADDRESSED IN AN ATTACHED TYPED AND SIGNED SHEET

 

  • Have you been addicted to, or illegally used, any prescription, controlled or illegal substance? _____ 

  • Has any Board ever taken action against your license? _____

  • Are there currently any outstanding complaints against your license in any jurisdiction? _____

  • Have you ever had a physical or mental illness or disability that impaired your ability to practice?_____

  • Have you ever pled guilty, nolo contendre, no contest, or been convicted or received probation before judgment for any criminal act, including DWI, DUI? _____

  • Has any hospital, clinic, HMO, or other healthcare entity denied you privileges? ____

  • Have you ever been found culpable for malpractice or settled a case for malpractice damages? _____

 

ATTESTATION:  I swear/affirm that the information given above is true and accurate to the best of my information and belief.

 _________________________________________________________________________

APPLICANT SIGNATURE                                                                            DATE

 

 

Application check-off: 

 _____  Legibly completed application

_____  Attached $650.00 fee

_____  Attached copy of current CPR Certification

_____  Contacted my State Board to have it send a certification of practice

 

 

FIRMLY  PASTE

 A  PASSPORT SIZED

PHOTO HERE

Photo MUST be of applicant taken within 60 days preceding the date of this application must he attached here

 Bust Size. Not Full Length

“Proofs” Not Acceptable

 Applicant must also furnish a DUPLICATE PHOTO endorsed across The front by signature

 IMPORTANT  NOTICE

This application, and photo static copies of college diplomas, to be the size of 8 ½" x II" inches must be attached to this application and filed in the office of the Board of Chiropractic Examiners, not later than 45 days preceding the date of the next scheduled examination. A letter of good standing, indicating original date to licensure, must be forwarded from the state where you currently practice.

CERTIFICATE OF APPLICATION

I HEREBY CERTIFY that I am the applicant mentioned in the foregoing application. I also certify that the photograph attached hereto is a true likeness of me taken on or about the _________ day of ____________, 20_________. 

 

  

 

 FINGERPRINT

OF  RIGHT

THUMB

 

  
 

 

FOR NOTARY USE:

State of : ____________________________________________________________

County of: ___________________________________________________________ 

I, _________________________________________________________, being duly sworn, says he/she is the person referred to in the foregoing application for a license to practice Chiropractic in Maryland and that _____ he/she has carefully read and thoroughly understands this affidavit and that the statements above are strictly true in every respect.________________________________________________________________

Signature of Applicant

Signed and sworn to before me this __________________ day of_____________________________ 20 _____________.

______________________________________________   ___________________________________________________
Notary Public Signature                                                                  Print Name

My commission expires ___________________________________, 20____________________.

 

 

 

 

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