Form Chi-4tmp - Application For Chiropractic Temporary Permit May 1999
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1STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
1109 Main Street, Suite 220
Boise, Idaho 83702-5642
APPLICATION FOR CHIROPRACTIC TEMPORARY PERMIT
An permit fee of $50.00 must be submitted with this application.
I hereby request authorization from the Idaho State Board of Chiropractic Physicians to engage in the temporary practice of
chiropractic in Idaho under the provisions of §54-711., Idaho Code, and provide the following:
1. Full Name (Mr., Mrs., or Ms.) _______________________________________________________________________________
2. Mailing address__________________________________________________________________________________________
Street/PO Box
City
State
Zip
3. Supervisor's Name _____________________________________________________
License # ____________________
4. Place of Business _________________________________________________________________________________________
5. Mailing address__________________________________________________________________________________________
Street/PO Box
City
State
Zip
6. Home phone _(____)_______________
Business phone _(____)______________
E-mail ______________________
AFFIDAVIT
I hereby certify that the responses provided above are true and accurate to the best of my knowledge and belief. I further certify that I
have read and will comply with the Idaho Laws and Rules and the adopted Scope of Practice governing the practice of Chiropractic in
Idaho. I further certify that I understand the obligations required by §54-711, Idaho Code, and will conduct my temporary practice in
the above named facility under the direct and immediate supervision of the above named supervisor. I acknowledge that I am required
to take the next scheduled board examination and that the temporary permit for which I am applying will expire either upon the date of
the examination or upon my receipt of the results of that examination. I understand that the temporary permit shall become
immediately null and void in the event I am determined to be ineligible for licensure
_____________________________________________________
Signature of applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 20 _____.
______________________________________________________
(seal)
Notary Public official signature
residing at_____________________________________________
my commission expires___________________________________
SUPERVISOR'S AFFIDAVIT
I hereby certify that I have read and understand the obligations required by §54-711, Idaho Code, and that I will serve as supervisor
for the above named applicant. I understand that my direct and immediate supervision will be in effect until the applicant completes
the next scheduled board examination and has received the results of that examination. I further understand that my supervision shall
immediately cease and the applicant's temporary permit shall become immediately null and void in the event the applicant is
determined to be ineligible for licensure. I further certify that, should I wish to terminate my supervision, I will give immediate
written notice of that termination by certified mail to the Idaho State Board of Chiropractic Physicians.
_____________________________________________________
Signature of applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 20 _____.
______________________________________________________
(seal)
Notary Public official signature
residing at_____________________________________________
my commission expires___________________________________
2
BOL – CHI-4TMP - 05/99
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