GENERAL INFORMATION AND INSTRUCTIONS …2. REQUIRED EXAMINATION INFORMATION: Maryland Laws and...

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Maryland Department of Health

Maryland State Board of Chiropractic Examiners 4201 Patterson Avenue, Suite 301

Baltimore, Maryland 21215

GENERAL INFORMATION AND INSTRUCTIONS

Application for Chiropractic Examination & Initial Licensure

HOW TO APPLY FOR MARYLAND CHIROPRACTIC LICENSURE – Pages 1 & 2

PLEASE TYPE INTO THE FORM OR PRINT IN BLACK INK - PLEASE READ CAREFULLY

1. MARYLAND LAWS & REGULATIONS:

You may download a copy of Code of MD Regulation, Title 10 Department of Health, Subtitle 43, Board of Chiropractic Examiners andthe Annotated Code of Maryland Health Occupations Title §3 -101 et al https://health.maryland.gov/chiropractic/Pages/regs.aspx. It isimportant to read this in order to determine your eligibility prior to applying and to familiarize yourself with the statute and

regulation regarding the chiropractic profession within the State of Maryland, its application and study guide.

2. REQUIRED EXAMINATION INFORMATION:

Maryland Laws and Regulations

National Board of Chiropractic Examiners (NBCE) Scores: Official Scores for parts I, II, III, & IV (required)

National Board of Chiropractic Examiners (NBCE) Scores: Official Scores for parts – Physiotherapy (optional)

3. UNDERGRADUATE TRANSCRIPT:

Attach Copies of Unofficial Transcript(s) to the Application for License to ensure seating for the MD State Board of ChiropracticExaminers Examinations.A final OFFICIAL TRANSCRIPT reflecting program completion/degree MUST be sent directly from the educational institution/collegeto this board office. Transcripts submitted by the applicant or indicating “issued to student” are not acceptable. A copy of your

diploma will not be accepted in lieu of an official transcript. Please note that it is your responsibility to follow-up with youreducational institutions to ensure that they have received and complied with your request(s).

4. CHIROPRACTIC COLLEGE TRANSCRIPT:

Attach Copies of Unofficial Transcript(s) to the Application for License to ensure seating for the MD State Board of ChiropracticExaminers Examinations.A final OFFICIAL TRANSCRIPT stating the degree and date of confirmation MUST be sent directly from the educationalinstitution/college to this board office. Transcripts submitted by the applicant or indicating “issued to student” are not acceptable. A

copy of your diploma will not be accepted in lieu of an official transcript. A student in a school or college of chiropractic, accreditedby the Council on Chiropractic Education or its successor in the final year of the program must have the college submit a letter withyour matriculation date and anticipated date of graduation on letterhead. Please note that it is your responsibility to follow-up withyour educational institutions to ensure that they have received and complied with your request(s). Please be advised, you will not beissued your passing score(s) or license until all required official documents facilitate a complete application which has been reviewed.

5. LICENSURE VERFICATION:

The licensure verification of “good standing” MUST be requested by the applicant from each state or other licensing authority where

you currently hold or have held a license to practice, regardless of the status of the license. The verification MUST be sent directlyfrom each state licensing agency to this board office. A copy of your license will not be accepted in lieu of an official verificationfrom the licensing agency. Please note that it is your responsibility to follow-up with your educational institutions to ensure that theyhave received and complied with your request(s).

6. APPLICANT'S QUESTIONS REGARDING APPLICATION STATUS:

The Application has a postmark deadline date which correspond with scheduled exam dates. Please review this information which

can be found on the board’s official website: www.health.maryland.gov/chiropractic homepage and scrolling down to theExamination icon. Within ten (10) days after we receive your application and fee, we will contact you informing you of anydeficiencies in your application and the specific items required to complete your application. If you do not receive an “Admit

Letter” notice to a scheduled examination notice within fifteen (15) days of the date you mailed it, or if you have questions

concerning the requirements for licensure, please do not hesitate to contact this office. If you have questions concerning whether

or not we have received items which we require you to arrange to be sent to this office by a third party (such as official transcripts,

licensure verifications from state licensing agencies); please check with the third party first to see if the required documentation

has been sent and then contact this board. Administratively as a reminder to all applicants, that an incomplete application shall

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expire one year after initial filing with the Board.

7. YES/NO QUESTIONS:

All questions with a "Yes or No” answer must be marked with either a "Yes" or "No" as no other response is acceptable. For questions which require a brief explanation or description to “Yes” answers, your responses must be sufficiently detailed to

ascertain the relevant dates, institution/organization names, and a brief synopsis of the reasons (i.e., the final charges or

substantiated allegations only) the institution/organization took the disciplinary or other action (i.e., probation, limitation,

suspension, revocation, voluntary relinquishment in lieu of disciplinary action, or any other adverse action).

8. FINGERPRINT CARD/BACKGROUND CHECK:

IN MARYLAND, THE PROCESS IS COMPLETED USING LIVE SCAN, WHICH IS AN ELECTRONIC FINGERPRINTING PROCESS. YOUR PRINTS WILL BE SENT TO BOTH THE MARYLAND DEPARTMENT OF JUSTICE (DOJ) AND THE FEDERAL BUREAU OF INVESTIGATION (FBI) TO SEARCH FOR ANY CRIMINAL HISTORY. All instructions regarding

the specific process are attached to this application (page(s) 10-13) If you live out-of-state, you MUST request a set of official fingerprint cards approved for this Board with the special board

authorization number AND ORI number PRIOR to completing the application for licensure. You will receive two cards (one

backup card). Please allow up to 10 business days to receive the fingerprint cards in the mail (refer to page(s) 10-13).

If you live in state (Maryland), the instructions and form are attached to this application (refer to page(s) 10-13).

9. RESCHEDULING A MD STATE BOARD OF CHIROPRACTIC EXAMINERS EXAMINATION: You may reschedule your examination appointment as needed, without penalty, up to 24 hours prior to your examination. IF you

fail to contact the board after you receive an “Admit Letter”, you will be considered a “No Show” and may be subject to a

regulatory Retake Fee of $400.

10. SPECIAL TESTING ACCOMMODATIONS:

Special Testing Accommodations due to Disability: Candidates requesting special testing accommodations must file a completed application. It is the responsibility of the candidate to provide adequate documentation of his/her disability.

11. CARDIOPULMONARY RESUSCITATION (CPR): Requires Healthcare Provider Level

12. MORAL CHARACTER REFERENCES: Forms are included within the Application Packet and MUST be completed by a

licensed chiropractor in good standing. Please have the attesting licensed chiropractor complete the form in its entirety and submit

directly to this Board before the application deadline.

13. FEE(S) SCHEDULE: A certified bank check or money order in the appropriate amount, made payable to the MD State Board of Chiropractic

Examiners, must be attached to your application. Please staple the check or money order to page 1 of the application on the

upper left part of the form. Your application will not be processed without these fees. These fees are required by law and

include the following:

1. Application for Initial Licensure and Required Jurisprudence Examination:

Application Fee $200.00 (non-refundable) required for licensing

JP Examination Fee $300.00 required for licensing

Total Fee $500.00

Supervising Chiropractor Examination : (Optional Exam– BUT REQUIRED TO TRAIN & SUPERVISE CHIROPRACTIC ASSISTANTS)

Must have Physiotherapy Score 375 or higher

Examination Fee $100.00

Total Fee $100.00 Note: Application & Both Exams Total $600.00

2. Initial License Fee: Only to be remitted to the Board after receiving written notification of a successful passing of the

MD State Board of Chiropractic Examiners Jurisprudence Examination (required) and the successful passing of the

Supervising Chiropractor Examination (optional).

Initial License Fee $200.00 for General Chiropractor (no PT) or Chiropractor with PT privileges

(Submit this fee only once you’re notified of passing the JP Exam) –Required

Initial License Fee – Supervising Chiropractor $250.00 for Supervising Chiropractor w/PT designation (Submit this fee only once

you’re notified of passing both the JP Examination and the Supervising Examination >

Must have NBCE physiotherapy score) - Optional

PLEASE NOTE – YOUR APPLICATION IS NOT CONSIDERED COMPLETE UNTIL ALL PAGES, SUPPORTING

DOCUMENTS ARE ENCLOSED/ORDERED AND FEES HAVE BEEN RECEIVED BY THIS BOARD OFFICE.

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Enter in box Last Name and Last 4 Digits of Social Sec. No.

APPLICATION FOR CHIROPRACTIC LICENSURE – PAGE 3

1. FEES: Please include ALL FEES in “ONE Certified Check or Money Order” made payable to the MD State Board of Chiropractic Examiners and Attach to Application

CHECK ALL THAT APPLY:

Application and Jurisprudence Examination Fee (required): $500.00

Supervising Chiropractic Examination Fee: (optional) $100.00 – Necessary to Train and Supervise C.A.’s (must

have a Physiotherapy score minimum of 375).

CHECK AND ENSURE THIS ITEMS ARE ATTACHED TO YOUR APPLICATION:

2. COPY OF UNDERGRADUATE TRANSCRIPT W/ APPLICATION (Request Official to be sent directly from

the institution/college to this board).

3. COPY OF CHIROPRACTIC TRANSCRIPT W/ APPLICATION (Request Official to be sent directly from

the institution/college to this board).

4. COPY OF CPR (Healthcare Provider Level)

*CHECK WHICH NATIONAL BOARD OF CHIROPRACTIC EXAMINERS – BOARD SCORE YOU PASSED:

5. NATIONAL BOARD SCORES [I, II, III, IV] (Request to be sent directly to this board from NBCE)

OR

*6. NATIONAL BOARD SCORES [I, II, III, IV and PHYSIOTHERAPY (Request to be sent directly to this board

from NBCE)

7. CRIMINAL HISTORY RECORDS CHECK RECEIPT W/ APPLICATION] (Complete the sendoff to CJIS)

8. TWO (2) 2 X2 PASSPORT STYLE PHOTOGRAPHS ON WHITE BACKGROUND W/ APPLICATION

9. TWO (2) MORAL CHARACTER REFERENCE FORMS COMPLETED (To be sent directly to this Board

by the D.C. completing the form)

10. VERIFICATION OF OTHER STATE LICENSURE (To be sent directly from the issuing state agency).

PLEASE NOTE:

All questions must be answered.

All “yes” answers to history must be supported by a certified copy of the final disposition of the case(s) from the clerk of court in the county where the conviction took place.

THIS SECTION - RE-EXAMINATION APPLICATION ONLY Complete and Submit Pages 3 & 4 ONLY if you have failed the MD Board Examination or had a “No Show” to scheduled examination date.

RE-EXAMINATION APPLICANT CHECKLIST

1. FEES: Please include the Fee in “ONE Certified Check or Money Order” made payable to the MD State Board of Chiropractic Examiners and ONLY send pages 3 & 4, after notification of failure by Bd.

Re-Examination Fee: $400 (Only if you have Failed or where a “No Show” for a previous MD State Board of Chiropractic Examiner’s Examination)

PLEASE NOTE:

If reapplying within one year from the original application DOCUMENTATION DOES NOT NEED TO BE RESUBMITTED.

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APPLICATION FOR CHIROPRACTIC LICENSURE – PAGE 4 (Complete All Pages)

APPLICATION FOR RE-EXAMINATION RETAKE (Complete Re-Examination Section Page(s) 3 & 4 and Profile Only)

READ THE PRECEEDING PAGES FOR IMPORTANT INFORMATION /TYPE INTO PDF FORM OR DOWNLOAD AND

PRINT LEGIBLY.

1. APPLICATION CATEGORY AND APPLICABLE FEES: (TYPE OR PRINT LEGIBLY IN BLACK INK)

[ ] INITIAL APPLICATION & EXAMNATION

Application + Jurisprudence Examination (required) TOTAL: $500.00

Add On – Supervising Chiropractic Exam (optional) TOTAL: $100.00 BOTH = $600.00

+

[ ] RE-EXAMINATION – ( i f a p p l i c a b l e d u e t o a p r i o r F a i l u r e o r “ N o S h o w ” )

MD Board Examinations – Required Jurisprudence TOTAL: $400.00 No. of Attempts: __

MD Board Examinations - Optional Supervising D.C. No. of Attempts: ___

2. APPLICANT PROFILE:

NAME: (Last) (First) (Middle)

Have you ever changed your name through marriage, naturalization or action of a court, or been known by any other name?

[ ] YES [ ] NO

If yes, provide the following: Name(s) (Last, First, Middle)

ADDRESS:

MAILING ADDRESS (where you receive mail):

(Street and number or PO Box) (City) (State/Province) (Zip/Postal Code) (Country)

PRIMARY PRACTICE/PHYSICAL ADDRESS (where you can be located-NO PO BOX):

(Street and number) (City) (State/Province) (Zip/Postal Code) (Country)

TELEPHONE: ( ) _( ) Primary: Area Code/Phone Number Business: Area Code/Phone Number

EMAIL ADDRESS:

(Email Notification: You will be responsible for checking your email regularly and updating your email address with the board office.

3. PERSONAL DATA:

BIRTH DATE: SOCIAL SECURITY NO. ____________________

(Month/Day/Year)

CITIZENSHIP:

We are required to ask that you furnish the following information as part of your voluntary compliance with this State. This information is gathered

for statistical and reporting purposes only and does not in any way affect your candidacy for licensure. Please check all that apply:

RACE/ETHNIC ID: White [ ] Black [ ] Hispanic [ ] Asian/Pacific Islander [ ] Native American [ ] Other [ ]

GENDER: Male [ ] Female [ ] Other [ ]

MILITARY VETERAN OR SPOUSE OF A VETERAN [ ] YES [ ] NO – Board’s Veteran Initiative No Fee for Application & Exam include ID

and if spouse – Military ID and Marriage Certificate

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4. EMPLOYMENT:

PRACTICE/EMPLOYMENT: List in chronological order from date of graduation to present date, all practice

employment, non-employment and/or any unaccounted period of time into Chiropractic school.

(Name of Business) (Full Mailing Address) (Type of Employment) (From: MM/DD/YYYY To: MM/DD/YYYY)



5. EDUCATION and TRAINING:

UNDERGRADUATE/GRADUATE/PROFESSIONAL EDUCATION: Please provide undergraduate, graduate, and professional

education, listing all schools, colleges and universities attended, whether completed or not, in chronological order.

(School Name) (City/State) (From: MM/DD/YYYY – To: MM/DD/YYYY) (Graduation Date) (Degree Awarded)




POSTGRADUATE TRAINING: List in chronological order from date of graduation from the Chiropractic School to the present, all professional

/postgraduate training (Internship/Residency/Fellowship).

(Program Name) (City/State or Country) (Program Type) (Specialty Area) (From: MM/DD/YYYY – To: MM/DD/YYYY) (Credit Received)

Y/N

(Program Name) (City/State or Country) (Program Type) (Specialty Area) (From: MM/DD/YYYY – To: MM/DD/YYYY) (Credit Received)

SPECIALTY BOARD CERTIFICATION:

SPECIALTY BOARD CERTIFICATION: Are you certified by any Specialty Board recognized by the American Chiropractic Association or International Chiropractic Association? [ ] YES [ ] NO

(If yes, please provide the following information and enclose a copy of each certification or letter of verification)

(Board Name) (Certification/Specialty/Subspecialty) (Date of Certification)

(Board Name) (Certification/Specialty/Subspecialty) (Date of Certification)

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APPLICATION FOR CHIRORPACTIC LICENSURE – PAGE 6

6. LICENSURE INFORMATION:

LICENSURE INFORMATION: Do you hold or have you ever held a license to practice Chiropractic or any other profession in any U.S. State or territory, or foreign country? [ ] YES [ ] NO

(If yes, please list the year where you legally began to practice. This would be the date you began practicing.

Year Began Practicing

/ / / /

License Type License Number State/Country Original Date Issued Expiration Date

/ / / /


/ / / /


PLEASE NOTE: Verification via an Official Verification of each license must be received directly from the licensing authority/agency,

regardless of status of license.

ALL AFFIRMATIVE ANSWERS MUST BE EXPLAINED IN DETAIL ON A SEPARATE SHEET.

DOCUMENTATION SUBSTANTIATING THE EXPLANATION IS REQUIRED.

7. PROCEEDINGS and/or ACTIONS

APPLICATION ACTIONS:

APPLICATION: 1. Have you had any application for professional license or any application

to practice Chiropractic denied by any state board or other governmental

agency of any state or country? [ ] YES [ ] NO

2. Have you ever been notified to appear before any licensing agency for a hearing

on a complaint of any nature including, but not limited to, a charge or violation

of the Chiropractic practice act, for healthcare unprofessional or unethical conduct? [ ] YES [ ] NO

If YES, please complete the following:

(Name of Agency) (City/State) (Date: MM/DD/YYYY) (Final Action) (Under Appeal? Y/N)

(Name of Agency) (City/State) (Date: MM/DD/YYYY) (Final Action) (Under Appeal? Y/N)

EDUCATION AND TRAINING:

EDUCATION/POSTGRADUATE TRAINING: 3. Have you ever been placed on probation, restrictions, suspension, revocation modification,

allowed to resign, requested to leave, temporarily or permanently or otherwise acted against

by a Chiropractic/Professional training program prior to completion of training? [ ] YES [ ] NO

If YES, list in chronological order from date of graduation from a Chiropractic/Professional college all professional/postgraduate training

disciplinary actions to the present.

(Program Name and full mailing address required) (Institution/Hospital) From: MM/DD/YYYY To: MM/DD/YYYY

(Program Name and full mailing address required) (Institution/Hospital) From: MM/DD/YYYY To: MM/DD/YYYY

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CRIMINAL HISTORY:

CRIMINAL INFORMATION: 4. Have you ever been arrested, charged, convicted of or entered a plea of guilty, nolo contendere,

or no contest to any crime in any jurisdiction other than a minor traffic offense? [ ] YES [ ] NO

If YES, you must include all misdemeanors and felonies, even if adjudication was withheld by the court so that you would not have a record of

conviction. Driving under the influence or driving while impaired is not a minor traffic offense for purposes of this question.

(Offense) (Date: MM/DD/YYYY) (Jurisdiction) (Final Disposition) (Under Appeal? Y/N)



LICENSURE ACTIONS:

LICENSURE ACTIONS: 5. Have you ever had any professional license or license to practice Chiropractic revoked, suspended,

placed on probation, received a citation, or other disciplinary action taken in any state, territory or

country? [ ] YES [ ] NO


(Name of Agency) (State) (Action Date: MM/DD/YY) (Final Action) (Under Appeal? Y/N)


6. Have you ever been the subject of a civil suit for negligence, malpractice or fraud? [ ] YES [ ] NO




[ ] YES [ ] NO

ADDITIONAL ACTIONS:

ADDITONAL ACTIONS: 7. Have you ever been discharged or separated from the U.S. Military or U.S. or state governments for less than honorable reasons including other than honorable administrative discharge?

[ ] YES [ ] NO If YES, please complete the following:


8. Are you now or have you ever been reliant on any drug, alcohol, prescription substance or controlled substance or medication? [ ] YES [ ] NO



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8. CHARACTER REFERENCE(S): As to character and reputation. I (applicant) refer you to the following licensed chiropractors in good standing (non-relatives)

who has known me for at least two (2) years. These individuals shall each complete and submit directly to this Board before the application deadline date for which I am anticipating to take the MD examination(s) their respective “Certificates of

Moral Character”. This Board can expect to receive the “Certificates of Moral Character” from the following Doctors of Chiropractic:

1.

(Printed Full Name) (Full Mailing Address - required) Email

Phone:__________________________________

2.

(Printed Full Name) (Full Mailing Address - required) Email

Phone:__________________________________

I hereby make application for Chiropractic Licensure according to the Maryland Chiropractic Act.

I have enclosed the Application and Examination(s) Fee of either $500 for General Chiropractor License or $600

for Supervising Chiropractor License by bank cashier’s check, business check or money order made payable to the

MD State Board of Chiropractic Examiners to which the application fee is Non-Refundable. If the application is

not completed within one (1) year, a new application must be filed and another application fee will be required.

I attest the facts and statements contained herein are true and accurate.

(Printed Full Name) (Signature - required) Date

NOTARY CERTIFICATION:

State:

County:

The undersigned notary public attests that the above-signed individual/applicant has presented photo identification

and has signed the above under oath/affirmation.

Signed and sworn to before me this ______day of __________, ______.

_______________________________________________ My Commission Expires: ____________ (SEAL) (Name and Signature)

Applicant - Pages 9 & 10 contain the Form – Certificate of Moral Character to be completed and submitted by your character references.

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APPLICATION FOR CHIROPRACTIC LICENSURE – PAGE 9 Maryland State Board of Chiropractic Examiners

4201 Patterson Ave., Suite 301

Baltimore, MD 21215

410-764-4726

www.health.maryland.gov/chiropractic

CERTIFICATE OF MORAL CHARACTER

(INSTRUCTIONS: To be completed by a Licensed Chiropractor in ‘Good Standing’. Note: You may go to the Board’s website

above and access the fillable PDF, then print out and send directly to this Board).

I hereby certify that I am personally and/or professionally acquainted with _____________________________________. (PRINT THE FULL NAME OF APPLICANT)

(the “Applicant”), to the degree that I can attest to the Applicant’s good moral character. I recommend the Applicant to the

Maryland State Board of Chiropractic Examiners as a person to be issued license and to professionally serve and protect

the health care public.

Please describe the manner in which you are familiar with the Applicant, including the length of time you have known the Applicant.

Are you aware of any facts relating to misconduct, administrative, criminal, or civil action against the Applicant that may affect the Applicant’s abilities as a chiropractor?

[ ] YES [ ] NO If yes, please explain in detail on the back of this page or email [email protected] providing the full name of the applicant (this form is required regardless of an email explanation). I attest that the information provided is true and correct to the best of my knowledge, information and belief.

NAME: _______________________________________________________________________________________ ____ (Print Full Name and Credentials) (Signature) (Date)

License # / Issuing State (or copy of license): _____________________ Date Issued:_______Expiration Date: _______

ADDRESS: _______________________________________________________________________________________ (Street No.) (City) (State) (Zip Code)

EMAIL: ___________________________________________ Contact Phone#: ____________________________

PLEASE DO NOT FORWARD THE COMPLETED FORM TO THE APPLICANT The completed form must be returned directly to the Board by the D.C. providing the certification.

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APPLICATION FOR CHIROPRACTIC LICENSURE – PAGE 10 Maryland State Board of Chiropractic Examiners

4201 Patterson Ave., Suite 301

Baltimore, MD 21215

410-764-4726

www.health.maryland.gov/chiropractic

CERTIFICATE OF MORAL CHARACTER

(INSTRUCTIONS: To be completed by a Licensed Chiropractor in ‘Good Standing’. Note: You may go to the Board’s

website above and access the fillable PDF, then print out and send directly to this Board).

I hereby certify that I am personally and/or professionally acquainted with _____________________________________. (PRINT THE FULL NAME OF APPLICANT)

(the “Applicant”), to the degree that I can attest to the Applicant’s good moral character. I recommend the Applicant to the

Maryland State Board of Chiropractic Examiners as a person to be issued license and to professionally serve and protect

the health care public.

Please describe the manner in which you are familiar with the Applicant, including the length of time you have known the Applicant.

Are you aware of any facts relating to misconduct, administrative, criminal, or civil action against the Applicant that may affect the Applicant’s abilities as a chiropractor?

[ ] YES [ ] NO If yes, please explain in detail on the back of this page or email [email protected] providing the full name of the applicant (this form is required regardless of an email explanation). I attest that the information provided is true and correct to the best of my knowledge, information and belief.

NAME:

_______________________________________________________________________________________ ____ (Print Full Name and Credentials) (Signature) (Date)

License # / Issuing State (or copy of license): _____________________ Date Issued:_______Expiration Date: _______

ADDRESS: _______________________________________________________________________________________ (Street No.) (City) (State) (Zip Code)

EMAIL: ___________________________________________ Contact Phone#: ____________________________

PLEASE DO NOT FORWARD THE COMPLETED FORM TO THE APPLICANT The completed form must be returned directly to the Board by the D.C. providing the certification.

Pages 11 of 13

MARYLAND STATE BOARD CHIROPRACTIC EXAMINERS

2018 BOARD EXAMINATION SCHEDULES

FOR

MD JURISPRUDENCE EXAMINATION &

SUPERVISING CHIRORPACTOR EXAMINATION

EXAMINATION DATE / TIME ROOM / APPLIC. POSTMARK DEADLINE DATE

JP EXAM & SUPV. CHIRO THURSDAY, FEB. 08, 2018 8:30 AM # TBA JAN. 08TH

JP EXAM & SUPV. CHIRO THURSDAY, APR. 12, 2018 8:30 AM # TBA MAR. 12TH

JP EXAM & SUPV. CHIRO THURSDAY, JUN. 14, 2018 8:30 AM # TBA MAY 15TH

JP EXAM & SUPV. CHIRO THURSDAY, AUG. 09, 2018 8:30 AM # TBA JUL. 09TH

JP EXAM & SUPV. CHIRO THURSDAY, OCT. 11, 2018 8:30 AM # TBA SEPT. 11TH

JP EXAM & SUPV. CHIRO THURSDAY, DEC. 13, 2018 8:30 AM # TBA NOV. 13TH

JP EXAM & SUPV. CHIRO






THURSDAY, FEB. 2019 TBA # TBA TBA







THURSDAY, APR. 2019 TBA # TBA TBA







THURSDAY, JUN. 2019 TBA # TBA TBA







THURSDAY AUG. 2019 TBA # TBA TBA







THURSDAY OCT. 2019 TBA # TBA TBA







THURSDAY DEC. 2019 TBA # TBA TBA

Laurie Sheffield-James,M.Div., Executive Director Adrienne Congo, M.S., Deputy Director 4201 Patterson Avenue, Suite 301 – Baltimore, Maryland 21215-2299

Chiropractic website: www.dhmh.maryland.gov/chiropractic Toll Free 1-877-4MD-DHMH TTY for Disabled – Maryland Relay Service 1-800-735-2258

STATE OF MARYLAND

DHMH Maryland Department of Health Maryland State Board of Chiropractic Examiners

Criminal History Records Check

A full Criminal History Records Check is a requirement for a license or registration from the Maryland Board of Chiropractic Examiners. A full background check includes both State and FBI checks. The Department of Public Safety and Correctional Services, Criminal Justice Information System (CJIS) oversees Criminal History Record Checks. History record checks are conducted by being fingerprinted.

CJIS AUTHORIZATION #: 0500119222

FBI ORI #: MD 920519Z

REASON FINGERPRINTED: Chiropractic, Chiropractic Asst License

TYPE OF CHECK: Governmental Licensing/Certification

The cost is $55.00 ($31.25 background check and $23.75 fingerprinting service). However, the cost of fingerprinting services from private providers can vary. The fee must be paid directly to the provider. For additional information contact CJIS at 410-764-4501 or visit www.dpscs.maryland.gov/publicservs/fingerprint.shtml.

All applicants for licensure or registration in Maryland will be required to submit fingerprints. This can be accomplished in two ways depending on if you are a Maryland resident or not. In order to comply with the regulations and not delay the issuance of a license or registration, follow the following directions.

http://www.dpscs.maryland.gov/publicservs/fingerprint.shtml

Laurie Sheffield-James,M.Div., Executive Director Adrienne Congo, M.S., Deputy Director 4201 Patterson Avenue, Suite 301 – Baltimore, Maryland 21215-2299

Chiropractic website: www.dhmh.maryland.gov/chiropractic Toll Free 1-877-4MD-DHMH TTY for Disabled – Maryland Relay Service 1-800-735-2258

Maryland Resident

1. Fill out and print a copy of the attached “Livescan Pre-registration Form”. Go towww.dpscs.maryland.gov/publicservs/fingerprint.shtml for a list of commercial fingerprint providers near you. Take the “Livescan Pre-registration Form” to the commercial fingerprint provider with you when you are fingerprinted.

2. When you have your fingerprints taken you will be given a receipt for payment. Include acopy of the receipt when filing your initial application.

3. Once the results of the background check are received which can take up to three weeks; theapplication process will be completed in accordance to Board regulations and policies. For additional information contact CJIS at 410 764-4501 or visit www.dpscs.maryland.gov/publicservs/fingerprint.shtml

Out of State Resident

1. If you live or work close to Maryland you can fill out and print a copy of the attached“Livescan Pre-registration Form”. Go to www.dpscs.maryland.gov/publicservs/fingerprint.shtml for a list of commercial fingerprint providers near you. Take the “Livescan Pre-registration Form” to the commercial fingerprint provider with you when you are fingerprinted. If not,

2. Before submitting a completed application, contact the Board 410 764-4738 to request an “Outof State Application for Criminal History Record Check” card.

3. Have your fingerprints taken at a law enforcement agency near you.

4. Once you have your prints taken you MUST mail the fingerprint cards to the below addresswith a check for $31.25 made out to the "CJIS Central Repository". No cash or money orders. Mail To: CJIS Central Repository P.O. Box 32708 Pikesville, Maryland 21282-2708

5. Mail a copy of the receipt for the fingerprinting to: Maryland Board of Chiropractic ExaminersATTN: Background Check 4201 Patterson Ave #301 Baltimore, Maryland 21215

6. Once the results of the background check are received, which can take up to four weeks; theapplication process will be completed in accordance to Board regulations and policies.




STATE OF MARYLAND DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY

LIVESCAN PRE-REGISTRATION APPLICATION

APPLICANT INFORMATION (PLEASE TYPE OR PRINT CLEARLY)

Name:

Date of birth: SSN: Gender: Male Female (Please check)

Height: ft. inches Weight: lbs. Eye Color: Hair Color:

Race: Black White )Asian/Pacific Islander Native American Other (Please check)

Place of Birth: Citizenship:

Current address:

City: State: ZIP Code: -

Daytime Phone: Evening Phone: Driver’s License #:

AGENCY INFORMATION

Agency Authorization #: 0500119222

ORI # (if required): MD 920519Z Reason fingerprinted? LICENSURE / REGISTR.

Position Applied for: MDH - MD STATE BOARD OF CHIROPRACTIC EX.

Request Type: (Choose one ONLY)

Adult Dependent Care Attorney/Client

Child care Criminal Justice

Gold Seal/ Adoption Gold Seal/Letter/VISA

Government Employment

Government Licensing or Certification Immigration/VISA

Individual Challenge Individual Review

MSP Licensing Private Party Petition

Public Housing

Mail Response to:

(Mailing option only available for Visa Gold Seal and/or Individual Review)

Name:

________________________________________________________________________________________

Address: _______________________________________________________________________________________

City, State, Zip code:

______________________________________________________________________________

GENERAL INFORMATION AND INSTRUCTIONS …2. REQUIRED EXAMINATION INFORMATION: Maryland Laws and...

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