List all professional specialties and evidence of expertise. For example: Orthopedics, Applied Kinesiology, Roentgenology.
Has any license entitling you to practice in any state or territory been suspended or revoked?
Have you ever been convicted of or pled guilty or nolo contendere to any violation of any law of any state, the United States or a foreign country? (Please exclude violations which resulted in a fine of less than $50)
Do you hold a license to practice previous to this date? (Please provide copy)
I am a CURRENT member of SORSI
I currently have malpractice insurance (please attach a copy)
Please list two references who can attest to your moral character...
#1 Reference Name
#2 Reference Name
Upload the following:
*Chiropractic License, *Copy of Malpractice Insurance, *Photograph, Suspension or Revocation Paperwork, Previous Licensure
I hereby certify (or declare) under penalty of perjury that the foregoing information contained in this application and any attachments is true and correct and that the attached photo are a true likeness of yself, the application identified herein.