MARYLAND BOARD OF CHIROPRACTIC & MASSAGE THERAPY EXAMINERS 4201 PATTERSON AVE., SUITE 301, BALTIMORE, MD 21215-2299 OFFICE - 410 764-4726 FAX- 410 358-1879 J. J. VALLONE, JD, CFE, EXECUTIVE DIRECTOR u ADRIENNE CONGO, MS, DEPUTY DIRECTOR Dear Applicant: The enclosed packet contains the information required to determine qualifications and application requirements for Maryland Licensure and the Jurisprudence Examination. THERE ARE ABSOLUTELY NO WAIVERS OR EXCEPTIONS TO THESE REQUIRENTS, INCLUDING THE MANDATORY 45 DAY DEADLINE FOR DOCUMENT/FEE SUBMISSIONS. DO NOT CALL AND REQUEST A WAIVER OR EXECEPTION. THESE REQUIREMENTS AND TIME FRAMES ARE SET BY REGULATION IN COMAR 10.43 ET SEQ. AND ARE NON-WAIVABLE. GENERAL: All applicants must have passed the NBCE Examination with scores as follows: PART I.375 Part II..375 Part III.375 Part IV.375 P.T.375 PHYSICAL THERAPY REQUIREMENTS: All applicants seeking P.T. privileges must achieve a minimum score of 375 on the P.T. section of the NBCE Examination. EXAMINATION SCHEDULE AND DEADLINES: All fees, applications, certificates of moral character, transcripts and examination scores MUST BE RECEIVED BY THE BOARD AT LEASE FORTY-FIVE (45) DAYS BEFORE THE SCHEDULE BOARD EXAMINATION DATE NO EXCEPTIONS, EXTENSIONS, OR WAIVERS. PLEASE DO NOT CALL THE BOARD AND REQUEST ANY EXTENSION OR WAIVER OR EXCEPTION THE BOARD DOES NOT CONFORM ITS EXAMINATION SCHEDULE TO THAT OF SCHOOLS OR THE NBCE; IT IS UP TO EACH APPLICANT TO CONFORM HIS/HER APPLICATION SUBMISSIONS TO MEET THE BOARD S DEADLINES. 2014 EXAMINATION SCHEDULE: ALL EXAMS START @ 8:30 A.M. April 10 th, June 12 th, August 14 th, October 9 th, December 11 th 1
FEES: A NON REFUNDABLE APPLICATION FEE OF $200.00 AND AN EXAMINATION FEE OF $300.00 MUST ACCOMPANY EACH APPLICATION; PAYABLE BY CHECK OR MONEY ORDER ONLY; PAYABLE TO: MD BOARD OF CHIROPRACTIC & MASSAGE THERAPY EXAMINERS. BAD CHECKS MAY BE DETERMINATIVE IN MATTERS OF TRUSE AND PROFESSIONAL MORAL TURPETUDE AND MAY ADVERSELY AFFECT YOUR APPLICATION STATUS. NO WALK-IN DELIVERIES OR CASH OR CREDIT CARD PAYMENTS ARE ACCEPTED. TRANSCRIPTS/EXAMINATION SCORES: ALL SCHOOL TRANSCRIPTS (UNDERGRADUATE AND CHIROPRACTIC COLLEGE) AND NBCE SCORES MUST BE SUBMITTED UNDER SEAL DIRECTLY BY THE SCHOOL AND/OR NBCE TO THE BOARD AND RECEIVED AT LEAST 45 DAYS PRIOR TO THE EXAMINATION DATE. DOCUMENTATION SENT FROM THE APPLICANT WILL NOT BE ACCEEPTED. PROCEDURES: AN APPLICATION FILE WILL BE PROCESSED UPON RECEIPT OF THE AFOREMENTIONED FEES AND DOCUMENTS. IT IS THE APPLICANT S EXCLUSIVE RESPONSIBILITY TO MEET ALL REQUIREMENTS AND DEADLINES. WHEN THE APPLICATION IS COMPLETE, THE BOARD INVESTIGATIVE UNIT WILL CONDUCT A FULL BACKGROUND CHECK THAT INCLUDES CRIMINAL BACKGROUND HISTORY, EMPLOYMENT, PRIOR LICENSING, TRAFFIC VIOLATIONS, ETC. ONCE THIS IS CLEARED, THE FILE IS FORWARDED TO THE BOARD EDUCATIONAL SUBCOMMITTEE FOR REVIEW AND EVALUATION. AT ITS DISCRETION, THE BOARD MAY SUMMON AN APPLICANT FOR AN INTERVIEW BY AN INVESTIGATOR, THE SUBCOMMITTEE OR THE FULL BOARD OR EXECUTIVE DIRECTOR. WHEN THE FILE IS APPROVED BY THE BOARD, A LETTER OF ADMISSION WILL BE SENT TO THE APPLICANT; THIS LETTER IS REQUIRED FOR ADMISSION TO THE EXAMINATION ALONG WITH AT LEAST ONE FORM OF OFFICIAL PHOTO IDENTIFICATION (PREFERABLY DRIVER LICENSE OR PASSPORT). QUESTIONS SHOULD BE ADDRESSED TO THE BOARD AT 410-764-4726 BETWEEN 8:30 AM AND 4:30 PM MONDAY THROUGH FRIDAY. MARYLAND BOARD OF CHIROPRACTIC & MASSAGE THERAPY EXAMINERS 4201 PATTERSON AVE., SUITE 301, BALTIMORE, MD 21215-2299 OFFICE - 410 764-4726 FAX - 410 358-1879 J. J. VALLONE, JD, CFE, EXECUTIVE DIRECTOR; ADRIENNE CONGO, MS, DEPUTY DIRECTOR 2
APPLICATION TO PRACTICE MARYLAND CHIROPRACTIC (All questions below must be specifically answered in legible format; the filing of this application does NOT grant any privilege to open a practice, office, institute a trade name or otherwise engage in any healthcare practice, including the practice of chiropractic. All applications are subject to investigation and verification of all personal and professional information, background and employment history and document check) I HEREBY MAKE APPLICATION FOR LICENSE TO CHIROPRACTIC IN ACCORDANCE WITH THE MD CHIROPRACTIC PRACTICE ACT. I HEREWITH ENCLOSE THE APPLICATION FEE OF $200. AND THE EXAMINATION FEE OF $300. UPON PASSING THE EXAMINATION, A $200. LICENSURE FEE WILL ALSO BE ASSESSED YOU WILL BE NOTIFIED WHEN THAT FEE IS DUE. APPLICATION FEES AND FEES SUBMITTED FOR AN EXAMINATION WHERE THE APPLICANT IS ABSENT WITHOUT EXCUSE ARE NON-REFUNDABLE. 1. Name in full Last first middle/maiden 2. Mailing address Street city zip code 3. Phone Number Cell Number Email 4. Date of Birth Place of Birth 5. Social Security Number Passport/Visa Number If not holding a social security number 6. Graduated from what High School (name, city, state) 7. Graduated from what undergraduate college 8. Undergraduate degree ; date of graduation ; honors 9. Graduated from what Chiropractic College 10. Chiropractic College date of graduation ; GPA ; Honors: 11. List other graduate schools or chiropractic colleges below. Use separate sheet if necessary. 12. Have you ever been expelled, suspended or formally disciplined while attending a chiropractic college? YES NO If yes, explain in detail on an attached sheet. 13. Has any license, registration, certificate, diploma or any other honor or entitlement been granted to you and subsequently suspended, revoked, withdrawn, or terminated for any reason? 3
14. Have you ever applied for and been denied or refused any license, registration, certificate, application, or entitlement by any state, federal or local licensing board? 15. Have you ever been charged, arrested or convicted of any crime (including traffic offenses, misdemeanors and felonies)? 16. Have you ever had any disciplinary action taken against you by any agency for any reason relating to treating the healthcare public or relating to the practice of healthcare services? 17. Are you now or have you ever been reliant on any drug, alcohol, prescription substance or controlled substance or medication? 18. Have you ever been the subject of a civil suit for negligence, malpractice, or fraud? 19. Have you ever been discharged or separated from the U.S. Military or U.S. or State Governments for less than honorable reasons including other than honorable administrative discharge? 20. Below, account for your last 5 years including work, education, occupations, achievements, etc: STATISTICAL INFORMATION: (The following is solely requested for statistical information purposes, you may decline to answer the following questions without any impact or effect on your ability to qualify for or achieve a Maryland license) RACE (check one) Latino/Latina ; African American Asian ; American Indian ; White ; Other GENDER: Male Female BIRTHDATE: CITIZENSHIP: U.S. Citizen Legal Alien (date of entry) 4
You must provide two (2) passport type color head and shoulder photos at least 2 x2 to 2 x3 on white background. Full body photos are NOT acceptable YES NO If yes, explain in Firmly paste one photo to this box and paper clip the other photo to this page. IMPORTANT REMINDER NOTICE: ALL GRADES, TRANSCRIPTS, SCORES, DIPLOMAS, TEST SCORES MUST BE SENT UNDER SEAL DIRECTLY FROM THE SCHOOL OR TESTING REGISTRAR CUSTODIAN. SUCH DOCUMENTATION RECEIVED FROM THE STUDENT WILL NOT BE ACCEPTABLE. THE ENTIRE COMPLETED APPLICATION PACKAGE MUST BE COMPLETED AND RECEIVED AT LEAST 45 DAYS PRIOR TO THE SCHEDULED JURISPRUDENCE EXAM OR THE APPLICANT WILL HAVE TO WAIT FOR THE NEXT SCHEDULED EXAM. YOU MUST PROVIDE AN INKED PRINT OF YOUR RIGHT THUMB IN THIS BOX - APPLICANT ATTESTATION/CERTIFICATION: I HEREBY ATTEST AND CERTIFY UNDER PENALTY OF LAW THAT I AM THE APPLICANT CITED IN THIS APPLICATION AND I FURTHER CERTIFY THAT THE PHOTOGRAPH HEREIN ATTACHED IS A TRUE LIKENESS OF ME TAKEN ON OR ABOUT THE DAY OF,. HEIGHT WEIGHT HAIR COLOR EYE COLOR OTHER IDENTIFYING MARKS APPLICANT SIGNATURE By my signature, I swear that I am the person referred to in the foregoing application and that I have carefully read and fully understand this attestation and that the statements are true and correct to the best of my knowledge and belief. NOTARIAL CERTIFICATION: State: County: The undersigned notary public attests that the above signed individual/applicant has presented photo identification and has signed above under oath/affirmation. Signed and sworn to before me this day of,. NOTARY SEAL Notary Public Name & Signature Date of expiration of Notary Commission 5
CERTIFICATE OF MORAL CHARACTER REQUIREMENT THESE CERTIFICATE SIGNATORIES WILL BE CHECKED BY THE BOARD INVESTIGATIVE STAFF. LIST ONLY CHARACTER REFERENCES WHO KNOW YOU AND CAN HONESTLY ATTEST TO YOUR MORAL CHARACTER. YOU MUST ATTACH TWO (2) OF THE COMPLETED FORMS ON PAGE 7 AND RETURN THEM WITH YOUR APPLICATION AND FEES. REFERENCE 1: NAME ADDRESS PHONE NUMBER EMAIL REFERENCE 2: NAME ADDRESS PHONE NUMBER EMAIL 6
CERTIFICATE OF MORAL CHARACTER: THE INDIVIDUAL COMPLETING THIS FORM MUST BE A LICENSED DOCTOR OF CHIROPRACTIC IN GOOD STANDING PLEASE TYPE OR PRINT LEGIBLY APPLICANT S NAME LAST FIRST MIDDLE THIS CERTIFIES THAT I AM PERSONALLY AND PROFESSIONALLY ACQUAINTED WITH THE ABOVE- NAMED CHIROPRACTIC APPLICANT TO THE DEGREE THAT I CAN ATTEST TO HIS/HER GOOD MORAL CHARACTER. I RECOMMEND HIM/HER TO THE MARYLAND BOARD OF CHIROPRACTIC & MASSAGE THERAPY EXAMINERS AS A WORTHY PERSON TO BE ISSUED A LICENSE AND TO PROFESSIONALLY SERVE AND PROTECT THE GENERAL PUBLIC WHO MAY PRESENT AS HIS/HER PATIENTS. ATTESTING DOCTOR NAME MAILING ADDRESS OFFICE PHONE CELL PHONE EMAIL I AM CURRENTLY LICENSED IN SINCE LICENSE NO. I HAVE KNOWN THE APPLICANT FOR: YEARS MONTHS I AM ACQUAINTED WITH THE APPLICANT (CHECK ALL THAT APPLY) PROFESSIONALLY STUDENT SOCIALLY RELATIVE BRIEFLY DESCRIBE HOW/WHY YOU CAN VOUCH FOR THIS APPLICANT (EXPLAIN BELOW & ON REVERSE SIDE) ARE YOU AWARE OF ANY FACTS RELATING TO MISCONDUCT, ADMINISTRATIVE OR CRIMINAL OR CIVIL ACTION AGAINST THE APPLICANT THAT MAY AFFECT HIS/HER ABILITIES AS A CHIROPRACTOR. YES NO (IF YES, DESCRIBE IN DETAIL ON REVERSE SIDE OF THIS PAGE) I ATTEST TO THE BEST OF MY KNOWLEDGE, BELIEF AND JUDGEMENT THAT THE APPLICANT HEREIN IS OF SOUND MORAL AND PROFESSIONAL CHARACTER AND IS DESERVING OF LICENSURE. SIGNATURE OF ATTESTING DOCTOR DATE OF SIGNATURE 7
STATE OF MARYLAND DHMH MD Board of Chiropractic & Massage Therapy Examiners Maryland Department of Health and Mental Hygiene 4201 Patterson Avenue Baltimore, MD 21215-2299 Chiropractic: 410-764-4726 Massage Therapy: 4107644738 Fax: 410-358-1879 Lawrence J. Hogan, Jr., Governor Boyd K. Rutherford, Lt. Governor Van T. Mitchell, Secretary Criminal History Records Check A full Criminal History Records Check is a requirement for a license or registration from the Maryland Board of Chiropractic and Massage Therapy Examiners. A full background check includes both State and FBI checks. The Department of Public Safety and Correctional Services, Criminal Justice Information System (CJIS) oversees Criminal History Record Checks. History record checks are conducted by being fingerprinted. CJIS AUTHORIZATION #: 0500119222 FBI ORI #: MD 920519Z REASON FINGERPRINTED: Chiropractic, Chiropractic Asst/Massage Therapy License TYPE OF CHECK: Governmental Licensing/Certification The cost is $52.75 ($32.75 background check and $20.00 fingerprinting service). However, the cost of fingerprinting services from private providers can vary. The fee must be paid directly to the provider. CASH IS NOT ACCEPTED. For additional information contact CJIS at 410-764-4501 or visit www.dpscs.maryland.gov/publicservs/fingerprint.shtml. All applicants for licensure or registration in Maryland will be required to submit fingerprints. This can be accomplished in two ways depending on if you are a Maryland resident or not. In order to comply with the regulations and not delay the issuance of a license or registration, follow the following directions. 4201 Patterson Avenue, Suite 301 Baltimore, Maryland 21215-2299 Chiropractic website: www.dhmh.maryland.gov/chiropractic Massage Therapy website: www.dhmh.mayland.gov/massage Toll Free 1-877-4MD-DHMH TTY for Disabled Maryland Relay Service 1-800-735-2258
Maryland Resident 1. Follow the directions in this letter and have your fingerprints taken prior to mailing in your application. You will need to have the CJIS Authorization number and FBI ORl # with you when you are fingerprinted. 2. When you have your fingerprints taken you will be given a receipt for payment. Include a copy of the receipt when filing your initial application. 3. Once the results of the background check are received the application process will be completed in accordance to Board regulations and policies. For additional information contact CJIS at 410 764-4501 or visit www.dpscs.maryland.gov/publicservs/fingerprint.shtml Out of State Resident 1. If you live or work close to Maryland you have the option of using a Maryland location for your fingerprinting. If you use a Maryland location you may follow the directions for Maryland residents. If not, 2. Mail in your application with all applicable documents and fees. 3. Once the Board receives your application you will be sent a set of fingerprint cards containing the CJIS Authorization number and the FBI ORI #. 4. Have your fingerprints taken at a location near you. For additional information contact CJIS at 410 764-4501 or visit www.dpscs.maryland.gov/publicservs/fingerprint.shtml 5. Once you have your prints taken you MUST mail the fingerprint cards to the below address with a check for $32.75 made out to the "CJIS Central Repository". Mail To: CJIS Central Repository P.O. Box 32708 Pikesville, Maryland 21282-2708 6. Mail a copy of the receipt for the fingerprinting to: Maryland Board of Chiropractic & Massage Therapy Examiners ATTN: Background Check 4201 Patterson Ave #301 Baltimore, Maryland 21215 7. Once the results of the background check are received the application process will be completed in accordance to Board regulations and policies. Electronic fingerprinting is required. Electronic fingerprinting locations are listed at: www.dpscs.maryland.gov/publicservs/fingerprint.shtml