Fillable (This Form Should Not Be Used For License (Michigan)

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(This Form Should Not Be Used For License (Michigan)

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LARA/BPL-CHIROAPP (9/19)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this
agency.
1 of 4
Bureau of Profes
sional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 241-0199
www.michigan.gov/bpl
BPLHelp@michigan.gov
APPLICATION FOR A CHIROPRACTIC LICENSE
Authority: 1978 PA 368
(This Form Should Not Be Used For License Renewal)
Print or Type Clearly
Applicant’s Legal Name (First, Middle, Last)
10-Digit MI Permanent ID/License Number (
If Applicable
)
U.S. Social Security #
(
New Applicants Only
)
Date of Birth
(
New Applicants Only
)
Address
City
State
Zip Code
Country
Telephone Number
Email Address
List any other name or alias by which you have ever been known, including maiden name, if applicable:
____________________________________________________________________________________
If applying for Educational Limited License, enter start date: ___________________________________________
CHECK THE LICENSE/OBTAINED BY METHOD FOR OFFICE USE ONLY
Chiropractic – By Endorsement $129.75 2301-09
Chiropractic – By Exam
$129.75 2301-01
Chiropractic – Relicensure $149.75 2301-06
Educational Limited $ 54.00 2301-03
Your check or money order, drawn from a U.S. financial institution
and made payable to the STATE OF MICHIGAN, must accompany
this request. DO NOT SEND CASH. Fees are non-refundable.
License Number
Issue Date
LARA/BPL-CHIROAPP (9/19)
2 o
f 4
Professional Education
(Attach additional sheets if necessary)
Name of School Name of Degree Granted
License(s) in Other State(s) and/or Country
List each state or country where you have ever held a chiropractic profession license, the license or registration
number, the date issued, how the license was obtained, and whether sanctions have ever been imposed against that
license or registration. (Attach additional sheets if necessary.)
I
f you indicate there have been sanctions imposed against a license or registration, you must submit documentation
that sanctions are not in force at the time of this application.
S
tate/Country
Permanent
License/Registration
Number
Date of
Issuance
How Obtained
(Examination/
Endorsement)
Have You Ever Had
Sanctions Imposed
Against this
Good Moral Character Questions
If you answer “yes” to either of the next two questions, you must submit a written explanation as to what took place
including date(s) of occurrence(s), court documents, documentation which shows at the current time you have the ability
to, and are likely to, serve the public in a fair, honest, and open manner, that you are rehabilitated, or that the substance
of the former offense is not reasonably related to the occupation or profession for which you are seeking a license.
A
nswering “yes” to the following question may not automatically prevent you from obtaining a license. In evaluating
your good moral character, the department will consider whether the substance of your former offense is reasonably
related to the profession to which you are seeking a license. Also, please know that you may request a preliminary
determination from the Department concerning whether any court judgments against you would likely result in a denial
of a license for failing to meet the good moral character requirement. More information about requesting a preliminary
determination can be found at www.michigan.gov/healthlicense
.
Have you ever been convicted of a felony? Yes No
Have you ever been convicted of a misdemeanor punishable by imprisonment for a maximum Yes No
term of two years or a misdemeanor involving the illegal delivery, possession, or use of alcohol
or a controlled substance?
LARA/BPL-CHIROAPP (9/19)
3 of 4
Required Additional Documents:
All Applicants
o Upon review of your application, you will be mailed an Application Confirmation letter containing instructions to
complete the Criminal Background Check (except those applicants seeking relicensure, if the license expired
within the last three years).
Chiropractor License by Endorsement
Applicants for licensure by endorsement who have been licensed in another state of the United States for 5
years or more immediately preceding the date of application must submit the following:
o Verification/certification of license to be submitted directly to this office by the licensing agency of any state of the
United States in which you hold a current license or ever held a license as a chiropractor. Verification includes, but
is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Applicants for licensure by endorsement who have been licensed in another state of the United States for less
than 5 years immediately preceding the date of application must submit the following:
o Certification of your examination scores submitted directly to this office from the examination agency. Contact the
National Board of Chiropractic Examiners (NBCE) to have the results of Parts I, II, III and IV of the national board
examination sent directly to this office. Contact the NBCE at 901 54
th
Avenue, Greeley, CO 80634 or (800) 964-
6223 or on their website at www.nbce.org
.
o Verification/certification of license to be submitted directly to this office by the licensing agency of any state of the
United States in which you hold a current license or ever held a license as a chiropractor. Verification includes, but
is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Chiropractor License by Exam
o Official final transcripts confirming having received a degree in chiropractic submitted directly to this office from a
chiropractic educational program accredited by the Council on Chiropractic Education.
o Certification of your examination scores submitted directly to this office from the examination agency. Contact the
National Board of Chiropractic Examiners (NBCE) to have the results of Parts I, II, III and IV of the national board
examination sent directly to this office. Contact the NBCE at 901 54
th
Avenue, Greeley, CO 80634 or (800) 964-
6223 or on their website at www.nbce.org
.
o Verification/certification of license to be submitted directly to this office by the licensing agency of any state of the
United States in which you hold a current license or ever held a license as a chiropractor. Verification includes, but
is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Educational Limited License (Non-renewable - issued for one 6-month period)
The educational limited license is issued for one 6-month period and can be issued only for the purpose of supervised
practice as part of your chiropractic education. If you have graduated from your chiropractic educational program, you
are NOT eligible for this license.
o Certification of Chiropractic Education form AND official transcripts submitted to this office directly from your
educational institution. You must have successfully completed at least 2 years of education in a college of arts and
sciences AND at least 1 of the following: 2 years, or four semesters, or six-quarter terms in an approved chiropractic
educational program accredited by the Council on Chiropractic Education.
o Supervision Confirmation Form. Forward the form to the supervisor of your education training for completion. It
must be submitted directly to this office by your supervisor.
LARA/BPL-CHIROAPP (9/19)
4 of 4
Relicensure
Applicants for relicensure whose license has lapsed for less than 3 years preceding the date of application must
complete the following:
o Submit proof of completing 45 hours of board-approved continuing education within the three years immediately
preceding the date of this application. At least 1 hour in pain and symptom management; 1 hour in sexual
boundaries; 1 hour of ethics; 2 live, in-person, hours in physical measures; and 2 live, in-person, hours in the area
of performing and ordering tests. Not more than 15 continuing education hours may be in board-approved distance
learning programs.
o Verification/certification of license to be submitted directly to this office by the licensing agency of any state of the
United States in which you hold a current license or ever held a license as a chiropractor. Verification includes, but
is not limited to, showing proof of any disciplinary action taken or pending disciplinary action imposed.
Applicants for relicensure whose license has lapsed for 3 years or more preceding the date of application must
complete the following:
o Submit proof of completing 45 hours of board-approved continuing education within the three years immediately
preceding the date of this application which includes the following: 24 live, in-person, board-approved continuing
education hours on chiropractic adjusting techniques. At least 1 hour in pain and symptom management; 1 hour in
sexual boundaries; 1 hour of ethics; 2 live, in-person, hours in physical measures; and 2 live, in-person, hours in the
area of performing and ordering tests. Not more than 15 continuing education hours may be in board-approved
distance learning programs.
o Verification/certification of license to be submitted directly to this office by the licensing agency of any state of the
United States in which you hold a current license or ever held a license to practice chiropractic. Verification includes,
but is not limited to, showing proof of any disciplinary action taken or pending action imposed.
o Satisfy either of the following:
o Submit verification that you have held a license to practice chiropractic in another state within 3 years
immediately preceding the application for relicensure.
OR
o Have successfully passed the special purposes exam for chiropractic (SPEC) of the National Board of
Chiropractic Examiners (NBCE). Provide certification of your passing examination scores submitted directly
to this office from the examination agency. The applicant shall request written authorization from the Bureau
of Professional Licensing (BPL) to take the exam and must pass the exam within 6 months after BPL issues
an authorization to test. Contact the NBCE to have the results the examination sent directly to this office.
Contact the NBCE at 901 54
th
Avenue, Greeley, CO 80634 or (800) 964-6223 or on their website at
www.nbce.org
.
CERTIFICATION AND SIGNATURE
I understand that it is the policy of this agency to secure a criminal conviction history as part of the pre-licensure screening
process. I authorize this agency to use the information provided in this application to obtain a criminal conviction history
file search from the Federal Bureau of Investigation, Central Records Division of the Michigan Department of State Police,
law enforcement, or judicial record-keeping organization. I consent to the release of information regarding a disciplinary
investigation conducted by a similar licensure, registration, or specialty licensure or specialty certification board of this or
any other state, of the United States military, of the federal government, or of another country.
I certify that the statements in this application are true and complete. I understand that any omitted statement,
misrepresentation, or fraud may be cause for denial of my application, disciplinary action, or may be punishable by law.
I further attest that I have a written policy for protecting, maintaining, and providing access to my medical records in
accordance with Section 16213 of the Public Health Code, 1978 PA 368, MCL 333.16213, and for complying with Section
16213 in the event that I sell or close my practice, retire from practice, or otherwise cease to practice under Article 15 of
the Public Health Code, 1978 PA 368, MCL 333.16101 to 333.18838.
_______________________________________________ ___________________________________
Signature Date
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(This Form Should Not Be Used For License (Michigan)

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Completed 9 February 2021

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