Chiropractor License Reinstatement Application

STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
Chiropractor Licensing
Email: dph.healingarts@ct.gov
Web Site: www.ct.gov/dph/license
Chiropractor License Application
Tape a recent photo
of applicant here.
DO NOT STAPLE
Please complete this application and submit it along with a check or money order in the amount of $565.00, made payable to “Treasurer, State of Connecticut." Return your completed application and fee to:
CT DPH, Chiropractor Application Processing, 410 Capitol Ave., MS# 12MQA, PO Box 340308, Hartford, CT 06134
Applicant*

First NameMILast Name
Social Security Number*
Social Security Number
Date of Birth*

MonthDayYear
Email Address*
example@example.com
Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemale
Hispanic or LatinoNot Hispanic or Latino
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite
YesNo
If yes, please list all (Please abbreviate. Attach additional sheets as necessary):

2-Letter State Abbreviation

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
License Number*
License Number
Professional Education School Name*

Professional Education School Name

Street Address Line 2

CityState

Degree Earned
Date Start*

MonthDayYear
End Date*

MonthDayYear
Pre-Professional Experience Location*

Pre-Professional Experience Location

Street Address Line 2

CityState

Zip Code
Start Date*

MonthDayYear
End Date*

MonthDayYear
YesNo
Have you ever been censured, disciplined, dismissed or expelled from, had admissions monitored or restricted, had privileges limited, suspended or terminated, been put on probation, or been requested to resign or withdraw from any of the following: Any hospital, nursing home, clinic, or similar institution; Any health maintenance organization, professional partnership, corporation, or similar health practice organization, either private or public; Any professional school, clinical clerkship, internship, externship, preceptorship; or postgraduate training program; Any third party reimbursement program, whether governmental or private?*

YesNo
YesNo
YesNo
YesNo
Have you ever been subject to, or do you currently have pending, any complaint, investigation, charge, or disciplinary action by any professional licensing or disciplinary body in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction or any disciplinary board/committee of any branch of the armed services? You need not report any complaints dismissed as without merit?*

YesNo
YesNo
YesNo
If you answered yes to any of the above questions regarding your professional history, please provide details in your own words in a separate notarized statement and provide supporting documentation (e.g. certified court copy with court seal affixed, complaint, answer, judgment, settlement or disposition) that will assist this office’s review.
NOTARIZATION: On this Day day of Month 20 Year (YY) , the above referenced individual personally appeared before me, who being duly sworn says that he/she is the person referred to in the foregoing application, the photograph attached hereto is a true picture of self and that the statements made herein or on any document attached hereto are true in every respect.

Sworn to before me this Day day of Month 20 Year (YY) .
Signature of Applicant *
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Signature of Notary Public
Enter Full Legal Name
I affirm or attest that this is my legal signature.
My commission expires

MonthDayYear
Should be Empty: