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4201 Patterson
Avenue, Baltimore, MD 21215-2299
(410) 764-4726
Web:
www.mdchiro.org
APPLICATION FOR LICENSURE BY CREDENTIALS
(Forms revised to conform to
regulatory revision enacted 10/22/07)
NON-REFUNDABLE APPLICATION FEE: $750.00 / LICENSE FEE: $650.00 (TOTAL FEES:
$1,400.00)
Licensure in
Maryland is a privilege, not
a right. The Board fully recognizes other jurisdictions’ licensure programs
that are similar to the requirements and standards of
Maryland.
Accordingly, the Board, pursuant to COMAR 10.43.04, may license chiropractors in
good standing from another jurisdiction providing that they meet the following
requirements:
-
Be currently licensed in
another state by virtue of passing an examination similar to that of Maryland
with full active practice in the FIVE (5) years immediately preceding
application;
-
Submit a sealed
verification of good practice certificate from the state in which practicing;
-
Take and pass the NBCE
SPEC and the Maryland Jurisprudence Examinations with minimum scores of 75%
(Note: The SPEC is waived for applicants who have successfully passed parts I
through IV of the NBCE, scoring a minimum of 438 on parts III and IV. If you
never took either parts III or IV, you must take the SPEC);
-
At the Board’s discretion,
submit to a further administrative and/or criminal background check and/or
personally interview before the Board of Examiners.
PLEASE TYPE OR PRINT ALL OF
THE FOLLOWING REQUESTED INFORMATION
FULL NAME:
________________________________________________________________________________________
Last
First Middle/Maiden
MAILING ADDRESS:
_________________________________________________________________________________
__________________________________________________________________________________________________
PHONE:
(_____)________________ CELL: (_____)________________ E-MAIL:
_______________________________
PLACE OF BIRTH:
___________________________________________________________________________________
Country
State County/City
SOCIAL SECURITY NO.:
____________________________ DRIVER LIC. NO.:
_________________________________
DATE OF BIRTH:
_______/________/_______
PLACE OF BIRTH:_______/________/_______
Rev. 11/2007
UNDERGRADUATE DEGREE AND
COLLEGE: ____________________________________________________________
DATE OF GRADUATION:
_____________________ HONORS:
________________________________________
LIST ANY POST-GRADUATE
DEGREES (OTHER THAN
CHIROPRACTIC COLLEGE) OR PROFESSIONAL CERTIFICATIONS OR TRAINING, INCLUDING
ARMED FORCES:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
CHIROPRACTIC
COLLEGE(S) ATTENDED:
_______________________________________________________________
___________________________________________________________________________________________________
GRADUATION DATE:
_______________ HONORS: __________________ DEGREE GRANTED:
________________
(IF DEGREE NOT GRANTED,
EXPLAIN IN DETAIL ON AN ATTACHED SHEET; PLEASE TYPE RESPONSE.)
PLEASE
ANSWER THE FOLLOWING. ALL ‘YES’ ANSWERS MUST BE EXPLAINED
IN DETAIL IN A TYPED
ATTACHED RESPONSE AND ALL SUPPORTING,
EXPLANATORY DOCUMENTATION
MUST ALSO BE ATTACHED.
-
Has any license,
certificate or diploma ever been revoked, suspended, or terminated for any
reason?
YES _____ NO
_____
-
Have you ever applied for
and been denied any license, certificate, application, security clearance,
diploma, or privilege to be issued by any agency, organization or business?
YES _____ NO
_____
-
Have you ever been charged
with or convicted of a crime (felony or misdemeanor) or been placed on
probation before judgment, or probation, or had any criminal charge/case
expunged, or been charged or convicted in a military trial by Court-Martial?
YES _____ NO
_____
-
Have you ever been
discharged from the military services under dishonorable or unsuitable or
other than honorable conditions?
YES _____ NO
_____
-
Have you ever been
investigated or charged with unprofessional conduct or malpractice?
YES _____ NO
_____
-
Have you ever been addicted to or dependent on any drug, chemical,
prescription medication, or alcohol?
YES _____ NO
_____
-
Have you ever had an
action of (including but not limited to) suspension, probation, admonishment,
reprimand, or other disciplinary or administrative action taken against a
professional license by any jurisdiction?
YES _____ NO
_____
-
Have you ever had or do
you now have any physical or mental incapacity that would prevent or preclude
you from safely and prudently treating patients?
YES _____ NO
_____
-
Have you ever filed
bankruptcy or been delinquent in paying fees to the Board or to other
agencies?
YES _____
NO _____
ATTESTATION
AFFIDAVIT
(To be
executed in the presence of a licensed notary)
I,
_________________________________________, hereby certify, swear and attest that
I am the applicant stated in the foregoing application and that the photo and
thumb print herein affixed are mine, taken on or about__________________,
20_____.
STATE
OF: _______________________________
COUNTY
OF: _______________________________
_______________________________________,
being duly sworn states that
he/she is the person cited in the foregoing application and attached
certificates of moral character for a license to practice chiropractic in
Maryland, and that he/she has carefully read and thoroughly understands this
application and affidavit, and that all statements made herein are true in every
respect to the best knowledge and belief of the affiant/applicant.
__________________________________________________________
APPLICANT SIGNATURE IN FULL
SIGNED
AND SWORN TO before
me, this ______ day of _____________, 20____.
__________________________________________________________________
SEAL
NOTARY PUBLIC SIGNATURE
MY
COMMISSION EXPIRES:
____________________________ , ____________
Revised: 11/2007
AUTHORIZATION FOR RELEASE OF RECORDS
AND/OR BACKGROUND CHECK
I,
______________________________________________________________, currently
residing at
___________________________________________________________________________________,
am an applicant for licensure in the State of Maryland. I give full and
complete authority for the release of any professional license record and/or any
record of criminal conviction(s) to the Maryland Board of Chiropractic Examiners
and its duly authorized representatives.
_______________________________ ___________________________
____/____/____
Name of
Applicant
Signature Date
Revised: 11/2007
MARYLAND BOARD OF
CHIROPRACTIC EXAMINERS
4201 Patterson Avenue,
Baltimore, MD 21215-2299
(410) 764-4726
Web:
www.mdchiro.org
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.: __________
___
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
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