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 |