Form 3 - Verification Of Chiropractic Licensure In Another Jurisdiction Page 2
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2SECTION II : VERIFICATION OF LICENSURE (Please Print All Information)
INSTRUCTIONS TO LICENSING AUTHORITY: Please complete this section. Be sure to sign and date the certification. This form must be returned
directly to the Office of the Professions. This form will not be accepted if returned by the applicant.
1)
Name of licensee: ____________________________________ _________________________________ ___________________________
First
Middle
Last
2)
Original Chiropractic License Number: ________________________________ Date of Licensure: ________ / ________ / ________
Mo.
Day
Yr.
3)
Was Chiropractor licensed based on successful completion of a clinical competency examination for skills and knowledge in:
YES
NO
YES
NO
X-ray Interpretation
Physical Diagnosis
Neurological and Orthopedic Testing
Chiropractic Technique
NO
NO
YES
YES
4)
Date of Examination: ________ / ________ / ________ Name of testing organization: ____________________________________________
Mo.
Day
Yr.
5)
If Chiropractor was licensed without examination, please explain: ___________________________________________________________
________________________________________________________________________________________________________________
6)
Has the licensee been disciplined in the past?
NO
YES
If Yes, explain: ____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7)
Are there currently any charges pending against the licensee?
NO
YES
If Yes, explain: ____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
CERTIFICATION
I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this form. I further certify that,
other than those listed above, this licensing authority has never taken any disciplinary action against this person and that, in so far as the licensing
authority has knowledge, there have been no charges preferred or sustained except as noted in questions 6 and 7 above.
Signature: ___________________________________________________________________ Date: ________ / ________ / ________
Mo.
Day
Yr.
Print name: _________________________________________________________________
(SEAL)
Title: _______________________________________________________________________
Agency: ____________________________________________________________________
Address: ____________________________________________________________________
Phone: ______________________________________________________________________
Fax: ________________________________________________________________________
E-mail: ______________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
TO:
Chiropractic Unit, 89 Washington Avenue, Albany, NY 12234-1000.
February 2004
FORM 3, PAGE 2 OF 2
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