Application for Certification Exam

Application For Certification Exam
If you have a test code, please enter it here.
SELECT ONE
Name
Name
First
Last
Office Address
Office Address
City
State/Province
Zip/Postal
Country
Billing same as office
Billing Address
Billing Address
City
State/Province
Zip/Postal
Country

Professional Education/College

Health/Chiropractic Education

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
#1 Reference Name
First
Last
#2 Reference Name
#2 Reference Name
First
Last
Maximum upload size: 4MB
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.

$USD
Credit Card