CHIROPRACTIC APPLICATION FOR RE-EXAMINATION
I hereby make application for a license to practice chiropractic in accordance with the Maryland Chiropractic Practice Act and all applicable regulations of the Board of Chiropractic Examiners for the State of Maryland. I herewith enclose the re-examination fee of $400.00. Remit by bank draft, certified check, or money order, made payable to: The Maryland Board of Chiropractic Examiners. Cash, credit cards, and personal checks are not accepted.
NAME: ______________________________________________________________
Last First Middle/Maiden
ADDRESS: ___________________________________________________________
___________________________________________________________
CITY: ____________________ STATE: __________ ZIP CODE: _____________
DATE OF BIRTH: ___/___/___ PLACE OF BIRTH: ______________________
SOCIAL SECURITY NUMBER: ________________________________________
TELEPHONE NO.: (___)__________ CELL/ALTERNATE NO.: (___)___________
E-MAIL ADDRESS: __________________________________________________
FOR BOARD USE ONLY
1. $400.00 re-examination fee paid: ________ YES ________ NO
2. Date(s) of last examination(s) taken: ________________________________________________
3. Score(s) of last examination(s): ________________________________________________
4. Qualifies for: Chiropractic license only: ____________
Chiropractic with PT privileges: ____________
5. Application for re-examination approved: ________ YES ________ NO
Revised: 10/2007
