Your Name:
Clinic Name:
Address:
Phone:
Your Email:
Is the Owner/Operator of the above noted clinic a chiropractor registered with the NLCB? YesNo (If No, please include a completed Form MDCD with your application)
Are you incorporated? YesNo
If Incorporated please provided your NLCB PCC#
Do you currently have professional liability protection/ insurance? If yes, please provided the carrier and coverage amount. YesNo
Carrier:
Amount:
Have you ever been charged with or convicted of a criminal offense? YesNo
If yes, please provide details on the charge or conviction.
In the event of my death, disability, or alteration to my practice status that prevents me from performing my custodial responsibilities for my patient files, I hereby assign: a licensed chiropractor in good standing with the NLCB, to assume custodianship of my patient files. I hereby attest to the fact that the above noted chiropractor has accepted this assignment of duties.
I confirm that the above information is accurate and I acknowledge that providing false information on this form or in any other communication with the NLCB may result in denial or revocation of license. I understand that it is my responsibility to inform the NLCB of any changes to the above information. I confirm