Forms and Publications
NOTE: THE BOARD DOES NOT ACCEPT CASH.
ALL PAYMENTS MUST BE MADE BY EITHER CHECK OR MONEY ORDER
ENFORCEMENT FORMS
| Form | Description | Revision Date |
|---|---|---|
| 1 | Authorization for Release of Patient Records | 12/2018 |
| 2 | Complaint Form | 11/01/2003 |
| 3 | Complaint Form in Spanish | 11/01/2003 |
| 4 | Guidelines for Petitioners (For Use with All Petitions) | 05/01/2001 |
| 5 | Petition for Early Termination of Probation (Form) | 05/01/2001 |
| 6 | Petition for Early Termination of Probation (Instructions) | 05/01/2001 |
| 7 | Petition for Penalty Reduction (Instructions) | 05/01/2001 |
| 8 | Petition for Penalty Reduction (Form) | 05/01/2001 |
| 9 | Petition for Reinstatement of License (Instructions) | 05/01/2001 |
| 10 | Petition for Reinstatement of License (Form) | 05/01/2001 |
| 11 | Quarterly Probation Report | 12/31/2018 |
| 12 | Reporting Requirements for Prosecuting Agencies and Court Clerks | 07/01/2004 |
LICENSING FORMS & APPLICATIONS
| Form | Description | Revision Date |
|---|---|---|
| 13 | Address Change Request | 12/2009 |
| 14 | Certification of Licensure and State Endorsement | 11/2003 |
| 15 | Chiropractic College Certificate | 02/2011 |
| 16 | Chiropractic License Application | 06/2017 |
| 17 | Corporation Registration | 10/1/2013 |
| 18 | Corporation Renewal | 02/2011 |
| 19 | Corporation Special Report (use for changes to existing corporations) |
02/2011 |
| 20 | Duplicate License/Name Change | 10/2010 |
| 21 | Inactive to Active Status Application Information Inactive to Active Status Application |
06/08/2011 |
| 22 | License Verification/Certification Request Form | 10/2010 |
| 23 | Live Scan Service Instructions and Form | 03/2002 |
| 24 | Prechiropractic Hours Verification | 02/2011 |
| 25 | Reciprocal License Application | 02/2011 |
| 26 | Referral Service Application | 07/2019 |
| 27 | Preceptor Form | 12/2018 |
| 28 | Replacement License Renewal Form | 07/2019 |
| 29 | Restoration of License | 04/2011 |
| 30 | Satellite Office (New, Renew, Cancel) | 02/2011 |
CONTINUING EDUCATIONÂ APPLICATIONS
| Form | Description | Revision Date |
|---|---|---|
| 31 | Continuing Education Provider Application | 02/2010 |
| 32 | Continuing Education Course Application (Must be a Board approved provider before completing this application) |
02/2010 |
CHIROPRACTIC COLLEGE APPLICATIONS
| Form | Description | Revision Date |
|---|---|---|
| 33 | Application for New Chiropractic College | 09/20/2006 |
AMBASSADOR REQUEST FORM
| Form | Description | Revision Date |
|---|---|---|
| 34 | Ambassador Request Form | 12/31/2018 |
