Free 51116.FH11 - Indiana

APPLICATION FOR A LIMITED TEMPORARY PERMIT TO PRACTICE CHIROPRACTIC
State Form 51116 (R / 8-06) Approved by State Board of Accounts, 2006

Reset Form

INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2054 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 DATE FEE PAID (month, day, year) RECEIPT NUMBER PERMIT NUMBER PERMIT ISSUANCE DATE (month, day, year) PHOTOGRAPH Attach one (1) passport-quality photograph taken within the last eight (8) weeks.

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*

(

)

NAME OF SCHOOL

CHIROPRACTIC SCHOOL OF GRADUATION LOCATION (city and state)

DATE OF GRADUATION (month, day, year)

CHIROPRACTIC LICENSES HELD (List all states, including Indiana, in which you have been licensed or certified to practice chiropractic.) STATE LICENSE NUMBER DATE ISSUED (month, day, year) DATE EXPIRES (month, day, year)

PURPOSE FOR TEMPORARY PERMIT
1. What is the purpose for applying for a temporary permit?

Page 1 of 4

PURPOSE FOR TEMPORARY PERMIT (continued)
2. What is the activity, organization, function, and event with regard to which the chiropractic services will be provided?

3. Specify type, extent, and specialization of chiropractic services to be provided.

LOCATION OF SERVICE
Name of practice Address (number and street or rural route) City T elephone number E-mail address State ZIP code

(

)

DATES OF SERVICE (A temporary permit is valid for a nonrenewable period of not more than thirty (30) days.)
Beginning date (month, day, year) Ending date (month, day, year)

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). Letters 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? Yes Yes Yes Yes Yes Yes Yes No No No No No No No

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)

Page 2 of 4

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 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 temporary permit. 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)

Page 3 of 4

VERIFICATION OF CHIROPRACTIC STATE LICENSURE FOR A LIMITED TEMPORARY PERMIT
Part of State Form 51116 (R / 8-06) 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 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. 2. 3. 4.

Please type or print. Complete the top section. Make copies to send to each state where you hold or have held a license. Request the state(s) to complete and return directly to: INDIANA BOARD OF CHIROPRACTIC EXAMINERS PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 APPLICANT INFORMATION

Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City, state, and ZIP code Telephone number (daytime) E-mail address

Social Security number*

(

)

License number

Date of issue (month, day, year)

AUTHORIZATION I hereby authorize the State of ______________________________ to provide the following information to the Indiana Board of Chiropractic Examiners.
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

Other (Please specify) __________________________________________________ Part III Part IV
Date of examination (month, day, year)

Physiotherapy

Name Title

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

Page 4 of 4