Return to Practice Application

I am applying to

Return to Full Time practice from Part Time practice.

Return to Part Time Practice from a Leave of absence.

Return to Full Time practice form a leave of absence.

An administrative fee of $ 70.00 must accompany this application for consideration by the Board. Other membership fees will apply when the application is approved.

Please select

Change of Category Application Fee$CA70

First name

Last name

Phone

Office Address

Details of Application

Requested start date of change

I understand that to modify my membership:

I must provideproof of liability protection, PLP, as provided by the
Canadian Chiropractic Protective Association, CCPA, or equivalent from another insurance carrier.
Have maintained continuing education requirements.
Have paid all membership fees as requested to date.

Signature