CA Renewal Notice (Fillable) by y486F4V


									                       OREGON BOARD OF CHIROPRACTIC EXAMINERS
LIC #:
RENEWAL DATE: July 31,                     (year)                           This is an Invoice for Payment

                                                                            PAYMENT DUE: $50
CA’s Name:                                                                  CE HOURS DUE: 6 *
                                                                           (*Any CA initially licensed between March 1 and
                                                                           May 31 of this year is exempt from the six (6)
                                                                           hour CE requirement; Payment IS still due.)
Read carefully and follow the Instructions.
1. Check YES or NO in answer to these questions. (“YES” answers require a full written explanation.)
   Since your initial license date or last renewal …
   (a) Have you been charged, arrested, or convicted of any misdemeanor or felony:               a. YES           or NO
       regardless of a dismissal or diversion?
   (b) Have you been, or are you in the process of being, disciplined by any other regulatory body?
                                                                                                 b. YES          or NO
2. Please write in any employment or home address CHANGES below.
    EMPLOYMENT INFORMATION (Please fill in ALL fields, if you are employed.)
    Doctor’s Name:
       City, State, Zip:
                         IS this a change from last year? Yes No                            * Notice: The OBCE is now
                                                                                            collecting email addresses so
                                                                                            we are able to send renewal
    CHIROPRACTIC ASSISTANT’S HOME ADDRESS                                                   reminders and notices to you
    Address:                                                                                electronically. Your email is
    City, State, Zip:                                                                       NOT public, or shared. Please
    Telephone:                                                                              provide your preferred email
    Email Address:
                      IS this a change from last year? Yes          No

                                     CONTINUING EDUCATION AFFIDAVIT
Do NOT SUBMIT CE verifications of attendance with your annual license renewal. The OBCE is on an audit system and
will request your proof of education later on. For now, sign and date this Affidavit verifying that you HAVE COMPLETED
the required continuing education.

Check ONE of the boxes below:

        I swear that I HAVE COMPLETED the required SIX hours CE within the immediate past 12 months as required by
        ORS 684.155 and OAR 811-010-0110(10(a) and (b).
        I am EXEMPT from the CE requirement in that I received my initial license between March 1 and May 31 of this
        same year.
        I have left the CA profession and am NOT renewing my CA certificate, or practicing after July 31.

       Failure to complete and submit ALL requirements by the Renewal Date (July 31) will cause the chiropractic
       assistant license to expire on July 31; Failure to comply by this deadline will require the CA to re-apply -
       retake the training, exam and pay the $110 initial fees.

By my signature below, I swear that all information hereon is true and correct, and that I have read this form thoroughly.

Signature:                                                                 Date:

Send your Payment and Renewal Notice/Affidavit to: OBCE, Unit 01, PO Box 4395, Portland OR 97208-4395

                   Questions? Contact the OBCE @ (503) 373-1573 or email

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