Fillable Printable Form 05174
Fillable Printable Form 05174
Form 05174
INDIANA BOARD OF CHIROPRACTIC EXAMINERS
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2054
E-mail: [email protected]
www.pla.IN.gov
DO NOT WRITE ABOVE THIS LINE
DATE OF GRADUATION (month, day , year)
APPLICATION FOR CHIROPRACTIC LICENSE
State Form 5174 (R11 / 9-17)
Approved by State Board of Accounts, 2017
APPLICANT
APPLICANT INFORMATION
Attach one (1) passport-quality
photograph taken not earlier than
one (1) year prior to the date of
application.
APPLICATION FEE
DATE FEE PAID (month, day, year)
RECEIPT NUMBER
LICENSE NUMBER
LICENSE ISSUANCE DATE (month, day, year)
LAW EXAMINATION DATE (month, day, year)
LAW EXAMINATION SCORE
BASIS FOR LICENSURE
If applying by examination, what date will you be taking or have taken the
National Board of Chiropractic Examiners - Part IV examination?
TEMPORARY PERMIT (EXAMINATION CANDIDATES ONLY - TAKING THE NBCE - PART IV EXAMINATION FOR THE FIRST TIME)
Do you wish to apply for a temporary permit?
CHIROPRACTIC SCHOOL OF GRADUATION
NAME OF SCHOOL LOCATION
EXAMINATION RECORD
NATIONAL BOARD OF CHIROPRACTIC EXAMINERS
NATIONAL BOARDS
Date of most recent test
(month, day, year)
WHERE TAKEN (State) HOW MANY TIMES?
PART I
PART II
PART III
PART IV
PHYSIOTHERAPY
Page 1 of 3
FOR OFFICE USE ONLY
Date of examination (month, day, year)
INSTRUCTIONS: 1. The fee for this application is $100.00, payable to the Indiana Professional Licensing Agency, in accordance with 846 IAC 1-4-7.
2. Completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
Yes No
Applying for licensure by: (Please check appropriate box.) Examination Endorsement
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
** This information is being requested for workforce statistical purposes only; disclosure is voluntary.
Name of applicant (last, first, middle)
Date of birth (month, day, year)
Address of applicant (number and street or rural route)
Social Security number
*
Telephone number (daytime)
( )
City, state, and ZIP code
E-mail address
Place of birth (city and state or country)
Gender **
Male Female
Pursuant to IC 12-32-1-5 and IC 12-32-1-6, I swear under the penalty of perjury that: (Please select one of the following.)
I am a United States Citizen. I am a qualified alien (as defined under 8 U.S.C. § 1641).
Race **Ethnicity **
Are you the spouse of a member of the military who is assigned to a duty station in Indiana?
(Optional)
Yes No
Are you an active duty member of the military? (Optional)
Yes No
Reset Form
EXAMINATION RECORD (continued)
If you are applying by endorsement, please list the State Board Examination you will be endorsing to the State of Indiana.
STATE EXAMINATION DATE (month, day, year) LICENSE CURRENT?
Yes No
PRE-PROFESSIONAL EDUCATION
NAME OF SCHOOL LOCATION
FROM
MONTH/YEAR
TO
MONTH/YEAR
DEGREE
PROFESSIONAL EDUCATION (SCHOOL OF CHIROPRACTIC)
NAME OF SCHOOL LOCATION
FROM
MONTH / YEAR
TO
MONTH / YEAR
DEGREE
Original state of licensure
License number
LIST ALL STATES INCLUDING INDIANA IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE CHIROPRACTIC
STATE LICENSE NUMBER
DATE ISSUED
(month, day, year)
DATE EXPIRES
(month, day, year)
ISSUED BY EXAMINATION OR
ENDORSEMENT?
LICENSED FOR THREE (3) YEARS
If you are applying by endorsement, please list the states where you have been licensed for three (3) years under qualifications substantially equivalent to Indiana.
STATE
LICENSE NUMBER
DATE ISSUED
(month, day, year)
DATE EXPIRES
(month, day, year)
LIST ALL PLACES YOU HAVE LIVED SINCE GRADUATION FROM CHIROPRACTIC SCHOOL
DATE (month, day, year)GENERAL LOCATION
Page 2 of 3
STATE BOARD EXAMINATION
Have you ever failed Part IV?
Yes No
If Yes, please state the date and location.
LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM CHIROPRACTIC SCHOOL
DATES OF
EMPLOYMENT
(month, day, year)
NAME AND ADDRESS OF EMPLOYER
RESPONSIBILITIES
1. Have you ever previously filed an application in the State of Indiana?
2. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held?
3. Have you ever been denied a license, certificate, registration or permit to practice chiropractic or any regulated health
occupation in any state (including Indiana) or country?
4. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor, or felony
in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
5. Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left
untreated may interfere, with your ability to practice in a competent and professional manner?
6. Have you ever had a malpractice judgment against you or settled any malpractice action?
I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant
Date signed (month, day, year)
APPLICATION AFFIRMATION
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize, request and direct any person, firm, officer, corporation , association, organization or institution to release to the Professional
Licensing Agency and the Indiana Board of Chiropractic Examiners any files, documents, records or other information pertaining to the undersigned
requested by the Agency, or any of its authorized representatives in connection with processing my application for chiropractic licensure.
I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to
such inspection or furnishing of any such information.
I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is
material to my application, and I hereby specifically release the Agency and Board from any and all liability in connection with such disclosure.
A photostatic copy of the authorization has the same force and effect as the original.
I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant
Date signed (month, day, year)
AFFIRMATION
Page 3 of 3
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent
revocation of the license or permit issued pursuant to this application.
Yes No
Yes No
Yes No
Yes No
DO NOT WRITE ABOVE THIS LINE
INDIANA BOARD OF CHIROPRACTIC EXAMINERS
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2054
E-mail: [email protected]
www.pla.IN.gov
Name of applicant (last, first, middle, maiden)
Address (number and street or rural route)
City
Telephone number (daytime)
School of graduation
APPLICATION FOR CHIROPRACTIC TEMPORARY PERMIT
(Examination Candidates Only)
Part of State Form 5174 (R11 / 9-17)
Approved by State Board of Accounts, 2017
FOR OFFICE USE ONLY
Social Security number*
Date of birth (month, day, year)
Date of graduation (month, day, year)
THIS SECTION TO BE COMPLETED BY THE APPLICANT
What date will you be sitting for the National Board of
Chiropractic Examiners - Part IV Examination?
Have you ever failed the National Boards - Part IV Examination?
Yes No
I understand that as a holder of a temporary permit I may not provide an independent diagnosis of a patient.
Date signed (month day, year)
Signature of applicant
THIS SECTION TO BE COMPLETED BY THE SUPERVISING CHIROPRACTOR
Name of supervisor
Address (number and street or rural route)
City
Telephone number
Social Security number*
Indiana license number Expiration date of license (month day, year)
PRACTICE LOCATION
Name of practice
Address (number and street or rural route)
City
I will be exclusively responsible for the direct supervision of the chiropractic graduate who is applying for this temporary permit.
Date signed (month day, year)
Signature of supervisor
Telephone number
State
ZIP code
State
ZIP code
State ZIP code
Temporary permit fee Date fee paid (month, day, year)
Receipt number
Temporary permit number Date issued (month, day, year)
( )
( )
( )
Date of examination (month, day, year)
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
INSTRUCTIONS: 1. The fee for a temporary permit is $50.00, payable to the Indiana Professional Licensing Agency, in accordance with 846 IAC 1-4-7.
INDIANA BOARD OF CHIROPRACTIC EXAMINERS
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2054
E-mail: [email protected]
www.pla.IN.gov
VERIFICATION OF CHIROPRACTIC STATE LICENSURE
Part of State Form 5174 (R11 / 9-17)
Approved by State Board of Accounts, 2017
INSTRUCTIONS: 1. Type or print and complete the top section.
2. Make copies to send to each state you hold or have held a license.
3. Request the state(s) to complete and send directly to:
INDIANA BOARD OF CHIROPRACTIC EXAMINERS
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2054
E-mail: [email protected]
APPLICANT INFORMATION
Name of applicant
Address (number and street or rural route)
City, state, and ZIP code
Date of birth (month, day, year)
Telephone number
Social Security number*
I hereby authorize the State of ______________________________ to furnish the Professional Licensing Agency with the information below.
Signature of applicant Date signed (month, day, year)
License number
Date of issue (month, day, year)
License number Date of issuance (month, day, year)
Expiration date (month, day, year)
Has the license been subject to disciplinary action? (Please attach copies of any disciplinary action taken by your board.)
Yes No
LICENSED BY
Examination Endorsement Other
National Boards Part I Part II Part III (WCCE) Part IV Physiotherapy
State examination administered?
Date of examination (month, day, year)
STATE EXAMINATION SUBJECTS AND SCORES
AREA ORAL / PRACTICAL APPLICANT'S SCORE PASSING SCORE
Chiropractic Technique
Orthopedic Testing
Neurological Testing
Physical Diagnosis
X-Ray Interpretation
Case Management
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Name
Title
State Board
Date (month, day, year)
Please Affix Board Seal
Yes No
E-mail address
( )
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
