Biennial Chiropractic License Renewal Page 2
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1
2
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4CHECK APPROPRIATE
RENEWAL OF AN ACTIVE LICENSE
LICENSE STATUS BOX
License #001 through #354 $ 400.00
(full license fee required for licenses issued more than 12 months ago)
License #355 and above
$ 200.00
(this prorated fee applies to licenses issued within the past 12 months)
RENEWAL OF OTHER LICENSE STATUS
Retired Status License
$ 100.00 (please refer to reactivation requirements in 12 AAC 16.390(c)-(e)
Inactive Status License
$ 100.00 (you must comply with continuing education requirements to qualify)
Name:
Last
First
Middle
Corrected Mailing Address (complete only if your address is different than the address label shown on first page).
Street or P.O. Box
City
State
ZIP Code
Daytime Telephone Number:
License Number:
Social Security Number:
Date of Birth:
Place of Employment:
PROFESSIONAL FITNESS
The following questions must be answered. "Yes" answers may not automatically result in license denial. Since your last license was
issued:
YES
NO
1. Has your license ever been denied, revoked, suspended, surrendered, stipulated, placed on probation, or been
subject to any other restriction, censure, reprimand, or disciplinary action in any jurisdiction? ...................................
1a. If the answer to the above question is “Yes,” provide the following information:
Name of the jurisdiction(s) in which action was taken:
Date of Action:
Have you previously reported this action to the Division of Occupational Licensing? .................................................
2. Have you engaged in illegal chiropractic practice, professional incompetence, lewd or immoral conduct, deceit,
fraud, intentional misrepresentation, or false advertising?...........................................................................................
3. Have you been convicted of any criminal offense other than a minor traffic violation? ...............................................
4. Do you have criminal charges pending against you?...................................................................................................
5. Have you experienced or been treated for bipolar disorder, schizophrenia, paranoia, a psychotic disorder,
substance abuse, or any other mental or emotional illness? .......................................................................................
6. Have you been addicted to or excessively or illegally used, or have you undergone treatment for the use of
alcohol, narcotics, or drugs? ........................................................................................................................................
7. Have you experienced a physical disability or an infectious or contagious disease? ..................................................
8. Have you had any malpractice settlements or judgments paid on your behalf? ..........................................................
AFFIDAVIT OF COMPLIANCE WITH CONTINUING EDUCATION REQUIREMENTS
Do you certify that you have complied with the continuing education requirements in
12 AAC 16.280-.390 during the license period from January 1, 1999, through December 31, 2000?
YES
NO
You must attach Forms A, B, C, D, and E (pages 3 and 4) to this application.
WARNING: Alaska Statute (AS) 11.56.210 states that any person who knowingly or intentionally furnishes false or fraudulent information
in this application is subject to imprisonment for not more than one years, a fine of not more than $5,000, or both. In accordance with
AS 08.20.170, the board may deny, suspend, or revoke the license of a person who has obtained or attempted to obtain a license to practice
chiropractic by fraud or deceit. In accordance with 12 AAC 16.380, falsification of written evidence submitted to the board regarding
continuing education requirements is unprofessional conduct and constitutes grounds for censure, reprimand, or license revocation or
suspension.
I certify under penalty of perjury that the information furnished in this application and on Forms A, B, C, D, and E is true and
correct.
Applicant's Signature
Date:
08-0094 (Rev. 10/00)
CONTINUED ON NEXT PAGE
Page 2
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