BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
DEPARTMENT OF CONSUMER AFFAIRS • CALIFORNIA BOARD OF CHIROPRACTIC EXAMINERS
901 P St., Suite 142A, Sacramento, CA 95814
P (916) 263-5355 | Toll-Free (866) 543-1311 | F (916) 327-0039 | www.chiro.ca.gov
Replacement Renewal Form
Complete this form and submit a check or money order in
the amount of $313.00 payable to "BOCE" to:
State of California
Board of Chiropractic Examiners
901 P Street, Suite 142A
Sacramento, California 95814
***INCOMPLETE FORMS WILL BE RETURNED ALONG WITH YOUR PAYMENT***
Check the box that applies to this renewal form: ACTIVE
License
INACTIVE
License
Type or print clearly
Name:
DC:
Current Practice Address:
License Expiration Date:
Answer the following questions
1.
Law Violations: During the last renewal period, have you been convicted of, or pled nolo contendere to, any
violation of a local, state, or federal law of any state, territory, country or U.S. federal jurisdiction?
YES NO
2.
Disciplinary Action: Have you had any disciplinary action taken against you by any other state regulatory agency?
If you answered "Yes" to either question, attach a detailed explanation with your renewal notice.
YES NO
3.
Continuing Education (CE): If renewing your license in active status; I certify that I have completed and can
document (if audited) 24 hours of Board-approved CE prior to my license expiration date, or that I have met the CE
exemption requirements.
I hereby certify that the information provided is true, correct and complete to the best of my knowledge. I also
certify that I personally read and completed this application and have read the instructions.
Signature: Date:
Complete if a change of name or address has occurred
Mailing Address, only if Inactive (P.O. Box acceptable)
(must attach legal documents with name change)
New Name:
ame:
N
Practice Address:
Mailing Address:
City:
State:
Zip:
City:
State:
Zip:
Phone Number:
Rev. 6/20
