Wyoming Board of Chiropractic Examiners 2001 Capitol Avenue, Room 104 Cheyenne, WY 82002 CHIROPRACTOR RESTORATION INSTRUCTIONS ELIGIBILITY An applicant may seek restoration if the applicant’s license expired within twelve (12) months. APPLICATION The Board requires receipt of the complete, original signed application; therefore, faxed and incomplete applications are unacceptable. The restoration fee of $400.00 (non-refundable) in the form of a cashier’s check or money order, made payable to the State of Wyoming must be mailed with the application. CONTINUING EDUCATION As a condition for restoration, licensee is required to complete a total of twelve (12) hours of acceptable continuing education every year as a condition of renewal. Criteria for continuing education can be found in Chapter 4 of the CURRENT Rules, available on the Board’s website at http://chiropractic.wyo.gov/rules-and-regulations. A minimum of eight (8) CE shall be earned at in person conferences or hands on training. A maximum of four (4) CE may be earned online. Certificates of completion must be included with your license restoration application. Copies of certificates of attendance must be provided with the restoration application form;
Wyoming Board of Chiropractic Examiners 2001 Capitol Avenue, Room 104 Cheyenne, WY 82002 CHIROPRACTOR RESTORATION APPLICATION Application fee is $400 Please type or print neatly.
1. Applicant Information Last Name
WY License #
Previous Names Used
2. Home Address Home Address
3. Business Address WYOMING Business Address
OTHER Business Address
4. Correspondence from Board Office I prefer to receive mail at my:
Email address is:
5. Active Practice I actively practiced as a chiropractor in 2016. If no, what year did you last practice?
5. Continuing Education To show completion of the required twelve (12) hours of continuing education, please itemize your continuing education below and attach copies of your certificates. Incomplete charts will be returned. DATE(S)
B C D
TOTAL HOURS SUBMITTED:
6. Practice History If you mark yes to any of the below questions, you must attach a detailed explanation. Provide copies of documentation if applicable.
a. Within the last five (5) years have you ever had any application for licensure or certification refused, dismissed, denied, or withdrawn by any professional licensing authority? b. Within the last five (5) years have you ever allowed any professional license to lapse in lieu of disciplinary action, or had a limited, conditioned, restricted, or probationary license issued by any licensing authority? c. Within the last five (5) years have you had a professional license revoked, voluntarily surrendered, suspended, reprimanded, censured, conditioned, restricted, or otherwise disciplined? d. Within the last five (5) years, have any unresolved or pending complaints ever been filed against you with any licensing agency or association? e. Is there any disciplinary action pending against you by any licensing agency or association? If YES, where and when? f. Within the last five (5) years have you ever been charged or convicted (including a nolo contendere plea or guilty plea) of a misdemeanor, felony, or other criminal offense (other than minor traffic violations) in any state or federal court? If YES, in addition to the affidavit, attach a certified copy of the court records regarding your conviction, the nature of the offense date of discharge, if applicable, as well as a statement from the probation or parole officer. g. Are you currently addicted to or abusing any chemical substance including alcohol (excluding tobacco and caffeine) that would impair your ability to practice? h. Do you currently have or have you been previously diagnosed with any condition or impairment (including but not limited to, substance abuse, alcohol abuse, or a mental, emotional or nervous disorder, or condition) that in any way affects your ability to practice in a competent, ethical, and professional manner? i. Within the last five (5) years, have you been named as a defendant to a civil suit related to your practice or profession (i.e. malpractice, Medical Review Panel)?
Yes No Yes No Yes No
7. Warning, Agreement, Affidavit, and Signature By signing this application:
I understand that making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 65-303.) I do hereby state that I have read, understand, and agree to abide by the rules and regulations promulgated by the Board of Chiropractic Examiners, and W.S. § 33-10-101 through 117. I also agree to adhere to the codes of ethics applicable to my profession and this application. I verify that I am the person making the foregoing statements and that they are made in good faith and are true in every respect.
SIGNATURE OF APPLICANT