Forms and Applications

NOTE: THE BOARD DOES NOT ACCEPT CASH.
ALL PAYMENTS MUST BE MADE BY EITHER CHECK OR MONEY ORDER

ENFORCEMENT FORMS

Form Description Fee Amount Revision Date
1 Authorization for Release of Patient Records  N/A  12/2018
2 Complaint Form  N/A  11/01/2003
3 Complaint Form in Spanish  N/A  11/01/2003
4 Guidelines for Petitioners (For Use with All Petitions)  N/A  05/01/2001
5 Petition for Early Termination of Probation (Form) $3,195 05/01/2001
6 Petition for Early Termination of Probation (Instructions)  N/A  05/01/2001
7 Petition for Penalty Reduction (Instructions)  N/A  05/01/2001
8 Petition for Penalty Reduction (Form) $3,195 05/01/2001
9 Petition for Reinstatement of License (Instructions)  N/A  05/01/2001
10 Petition for Reinstatement of License (Form) $4,185 05/01/2001
11 Quarterly Probation Report  N/A  12/31/2018
12 Reporting Requirements for Prosecuting Agencies and Court Clerks  N/A  07/01/2004

LICENSING FORMS & APPLICATIONS

Form Description Fee Amount Revision Date
13 Address Change Request  N/A  12/2009
14 Certification of Licensure and State Endorsement  N/A  11/2003
15 Chiropractic College Certificate  N/A  02/2011
16 Chiropractic License Application $345 06/2017
17 Corporation Registration $171 10/1/2013
18 Corporation Renewal $62 02/2011
19 Corporation Special Report
(use for changes to existing corporations)		 $98 02/2011
20 Duplicate License/Name Change $71 10/2010
21 Inactive to Active Status Application Information
Inactive to Active Status Application 		$336 06/08/2011
22 License Verification/Certification Request Form $83 10/2010
23 Live Scan Service Instructions and Form  N/A  03/2002
24 Prechiropractic Hours Verification  N/A  02/2011
25 Reciprocal License Application $283 02/2011
26 Referral Service Application $279 07/2019
27 Preceptor Form $72 12/2018
28 Replacement License Renewal Form $336 07/2019
29 Restoration of License $672 04/2011
30 Satellite Office (New, Renew, Cancel)  New: $69
Renewal: $50
Cancel: No Fee 		 02/2011

CONTINUING EDUCATION APPLICATIONS

Form Description Fee Amount Revision Date
31 Continuing Education Provider Application New: $291
Renewal: $118		 02/2010
32 Continuing Education Course Application
(Must be a Board approved provider before completing this application)		  $116 per hour of instruction  02/2010

CHIROPRACTIC COLLEGE APPLICATIONS

Form Description Fee Amount Revision Date
33 Application for New Chiropractic College N/A 09/20/2006

AMBASSADOR REQUEST FORM

Form Description Fee Amount Revision Date
34 Ambassador Request Form N/A 12/31/2018