Free 05174.FH11 - Indiana

APPLICATION FOR CHIROPRACTIC LICENSE
State Form 5174 (R7 / 2-06) Approved by State Board of Accounts, 2006

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INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER LICENSE ISSUANCE DATE (month, day, year) LAW EXAMINATION DATE (month, day, year) LAW EXAMINATION SCORE APPLICANT Attach one (1) passport-quality photograph taken not earlier than one (1) year prior to the date of application.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Date of birth (month, day, year) Telephone number (daytime) Place of birth (city and state or country) E-mail address State ZIP code Social Security number*

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BASIS FOR LICENSURE Application for licensure by: (Please check appropriate box.) EXAMINATION If applying by examination, what date will you be taking or have taken the National Board of Chiropractic Examiners - Part IV examination? ENDORSEMENT
Date of examination (month, day, year)

Date of examination

TEMPORARY PERMIT (EXAMINATION CANDIDATES ONLY - TAKING THE NBCE - PART IV EXAMINATION FOR THE FIRST TIME) Do you wish to apply for a temporary permit? Yes NAME OF SCHOOL No LOCATION DATE OF GRADUATION (month, day, year) CHIROPRACTIC SCHOOL OF GRADUATION

EXAMINATION RECORD NATIONAL BOARD OF CHIROPRACTIC EXAMINERS NATIONAL BOARDS PART I PART II PART III PART IV PHYSIOTHERAPY Have you ever failed Part IV? (If Yes, please state the date and location.) Yes Page 1 No Date of most recent test (month, day, year) WHERE TAKEN (State) HOW MANY TIMES?

EXAMINATION RECORD (continued) STATE BOARD EXAMINATION If you are applying by endorsement, please list the State Board Examination you will be endorsing to the State of Indiana. STATE EXAMINATION DATE (month, day, year) LICENSE CURRENT? Yes PRE-PROFESSIONAL EDUCATION NAME OF SCHOOL LOCATION FROM MONTH/YEAR TO MONTH/YEAR DEGREE No

PROFESSIONAL EDUCATION (SCHOOL OF CHIROPRACTIC) NAME OF SCHOOL LOCATION FROM MONTH/YEAR TO MONTH/YEAR DEGREE

Original state of licensure

License number

LIST ALL STATES INCLUDING INDIANA IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE CHIROPRACTIC STATE LICENSE NUMBER DATE ISSUED DATE EXPIRES ISSUED BY EXAMINATION OR ENDORSEMENT?

LICENSED FOR THREE YEARS If you are applying by endorsement, please list the states where you have been licensed for three (3) years under qualifications substantially equivalent to Indiana STATE DATE ISSUED DATE EXPIRES LICENSE NUMBER

LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM CHIROPRACTIC SCHOOL GENERAL LOCATION DATE

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LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM CHIROPRACTIC SCHOOL NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES DATES OF EMPLOYMENT

If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. If malpractice, provide name(s) of plaintiff(s). Letter from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Have you ever previously filed an application in the State of Indiana? 2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held? 3. Have you ever been denied a license, certificate, registration or permit to practice chiropractic or any regulated health occupation in any state (including Indiana) or country? 4. Are you now being, or have you ever been, treated for drug or alcohol abuse? 5. Have you ever been convicted of, plead guilty or nolo contendere to: A. A violation of any Federal, State, or local law relating to the use, manufacturing, distribution or dispensing of controlled substances or drug addiction. B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines.) 6. Have you ever had a malpractice judgment against you or settled any malpractice action? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct. Signature of applicant Date signed (month, day, year) Yes Yes Yes Yes Yes Yes Yes No No No No No No No

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation , association, organization or institution to release to the Professional Licensing Agency and the Indiana Board of Chiropractic Examiners any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for chiropractic licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and I hereby specifically release the Agency and Board from any and all liability in connection with such disclosure. A photostatic copy of the authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same. Signature of applicant Date signed (month, day, year)

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APPLICATION FOR CHIROPRACTIC TEMPORARY PERMIT (Examination Candidates Only)
Part of State Form 5174 (R7 / 2-06) Approved by State Board of Accounts, 2006

INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY
Temporary permit fee Temporary permit number Date fee paid (month, day, year) Receipt number

Date issued (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Telephone number (daytime)

THIS SECTION TO BE COMPLETED BY THE APPLICANT
Social Security number*

State Date of birth (month, day, year) Date of graduation (month, day, year)

ZIP code

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School of graduation

What date will you be sitting for the National Board of Date of examination (month, day, year) Chiropractic Examiners - Part IV Examination?

Have you ever failed the National Boards - Part IV Examination? Yes No

I understand that as a holder of a temporary permit I may not provide an independent diagnosis of a patient.
Signature of applicant Date signed (month day, year)

THIS SECTION TO BE COMPLETED BY THE SUPERVISING CHIROPRACTOR
Name of supervisor Address (number and street or rural route) City Telephone number Indiana license number State ZIP code Social Security number*

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Expiration date of license (month day, year)

PRACTICE LOCATION
Name of practice Address (number and street or rural route) City State ZIP code Telephone number

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I will be exclusively responsible for the direct supervision of the chiropractic graduate who is applying for this temporary permit.
Signature of supervisor Date signed (month day, year)

VERIFICATION OF CHIROPRACTIC STATE LICENSURE
Part of State Form 5174 (R7 / 2-06) Approved by State Board of Accounts, 2006

INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] www.pla.IN.gov

*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

INSTRUCTIONS:

1. Type or print and complete the top section. 2. Make copies to send to each state you hold or have held a license. 3. Request the state(s) to complete and send directly to: INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 E-mail: [email protected] APPLICANT INFORMATION

Name of applicant Address (number and street or rural route) City, state, and ZIP code Date of birth (month, day, year) Telephone number License number E-mail address

Social Security number*

Date of issue (month, day, year)

I hereby authorize the State of ______________________________ to furnish the Professional Licensing Agency with the information below.
Signature of applicant Date signed (month, day, year)

License number

Date of issuance (month, day, year)

Expiration date (month, day, year)

Has the license been subject to disciplinary action? (Please attach copies of any disciplinary action taken by your board.)

Yes

No LICENSED BY

Examination National Boards
State examination administered?

Endorsement Part I Part II Yes No Part III (WCCE)

Other Part IV Physiotherapy

Date of examination (month, day, year)

STATE EXAMINATION SUBJECTS AND SCORES AREA Chiropractic Technique Orthopedic Testing Neurological Testing Physical Diagnosis X-Ray Interpretation Case Management
Name Title

ORAL / PRACTICAL Yes Yes Yes Yes Yes Yes No No No No No No

APPLICANT'S SCORE

PASSING SCORE

Please Affix Board Seal
State Board Date (month, day, year)