Biennial Chiropractic License Renewal Page 4
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License Number:
FORM C
INSTRUCTOR OR DISCUSSION LEADER
Instructor or discussion leader credit is awarded on an hour-for-hour basis. Credit for preparation under this section may not exceed
twice the number of hours credited for actual instruction. The maximum credit allowable as an instructor or discussion leader may
not exceed eight hours. Repeated presentations will not normally qualify and must be explained.
X-ray
Hours
Name and Address of Program Sponsor
Location of
Dates
Total
Include
(if the complete mailing address is not included, this
Program
Program Title
Attended
Hours
in
form will be returned as incomplete)
(City)
or Description
(Mo/Day/Yr)
Claimed
Total
FORM D
PUBLISHED ARTICLES AND BOOKS
The number of hours of continuing education credit awarded will be determined by the board on an individual basis.
X-ray
Hours
Name and Address of Program Sponsor
Location of
Dates
Total
Include
(if the complete mailing address is not included, this
Program
Program Title
Attended
Hours
in
form will be returned as incomplete)
(City)
or Description
(Mo/Day/Yr)
Claimed
Total
FORM E
Two hours of approved continuing education credit may be awarded for reading the Board of Chiropractic Examiners Statutes
and Regulations book and completing the affidavit below.
AFFIDAVIT OF COMPLIANCE WITH THE REQUIREMENT TO READ THE
THE BOARD OF CHIROPRACTIC EXAMINERS STATUTES AND REGULATIONS BOOK
Do you certify that you have read the Board of Chiropractic Examiners Statutes and Regulations book in its entirety, in accordance with
12 AAC 16.290(d)?
Yes
No
Signature
08-0094 (Rev. 10/00)
Page 4
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