Applicants, Licensing and Registration Forms

Chiropractors

• Doctor of Chiropractic License Application (Fillable PDF or Print Out and complete.  Must be signed and notatrized.)
• Application Package
• Certificate of Moral Character Forms to be completed by Licensed D.C. & sent by that D.C.
• Criminal History Records Check - Fingerprinting Instructions
• MD Fingerprinting Form - In State Only
  
• Out of State Fingerprinting MUST contact Board for Fingerprint Card first
• PDF Fillable "Certificate of Moral Character Form" to be completed and sent by licensed D.C. directly to the Board.
• D.C. Application for Re-examination
• Criminal History Records Check Form and Instructions
  

Licensed Chiropractors

• Application for Licensure by Waiver For Visiting Chiropractor
• Application for Re-examination 
• ​ Continuing Education Guidelines and Forms
• Externship Application (Recent Graduate and Out-of-State DC only)
• Preceptorship Application (Students only)
• Preceptor Sponsor Application
• Preceptor’s Final Evaluation
• Supervising Chiropractor Application 
• Dry Needling Registration Application Form
• Criminal History Records Check Form and Instructions

Chiropractic Assistant Applicants

CA Training Program
Stage 1:  Request To Employ (4 Page Packet with all required documents must be submitted)

• CA Training Program Guidelines AND CA Applicant/Trainee “Request to Employ” Packet
• Application Packet includes:   
• Supervising D.C. (Pages 1 & 2 to complete)
• CA Trainee (Pages 3 & 4 to complete)
• Criminal History Records Check Instruction & Form
• Notification of Hiring an Active Registered CA
• Change of Status (for CA Trainees and Registered CAs)
• Notice of Transfer (for CA Trainees and Registered CAs)

Stage 2  4-Month Review (DC is responsible for submitting documents)

• 4 Month Review Form
• Form
• MUST include copy of CPR certification and Proof of enrollment in Board approved CA Instructional Coursework

Stage 3 - Application for Examination and Registration (with all required fees and documentation) must be submitted by the deadline on the posted examination schedule.

• CA Application for Registration   
• Application
• Certificate of Moral Character
• Clinical Training Log
  
• Certificate of 103 CA Coursework completion
• Provider Level CPR (should have been submitted at 4-month review)
• Criminal History Record Check - Fingerprinting (copy of receipt)
• Application To Retake Chiropractic Assistant Examination​(for CA Trainee)
  
• CA ​Late Renewal / Late Inactive Status Application

Additional Forms

• Inactive Status Application (DC & CA)
• Reinstatement and Reactivation Application (DC & CA)​
  
• Complaint Form
• Notification of Address Change (DC, CA, & CA Trainee)
• Notification of Name Change (DC & CA)
  
• Request for Duplicate License (DC & CA)
• Request for Replacement License (DC & CA)
• Request for License Verification (DC & CA)
• Roster Request​
  
• Special Accommodations Request (Exam Applicants-Requires Medical/School documentation)
• Continuing Education Unit Course Approval Application