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 EDUCATION 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