APPLICATION FOR APPOINTMENT AS CONSULTANT TO THE COLORADO STATE

Name: ____________________________________________________________
(Last, First, Middle)

 Colorado License Number and Issue Date: ____________________________________

Years In Active Chiropractic Practice: ________________________________________

Office Address: _________________________________________________________
Street City State Zip Code

 Home Address: ________________________________________________________
Street City State Zip Code

 List all other professional licenses, which you may hold

 Memberships and Offices held in Professional Societies

 __________________________________________ From _______ To _______

 __________________________________________ From _______ To _______

 __________________________________________ From _______ To _______

 (attach additional sheets if necessary)

 ____________________________________________________________________

 (attach additional sheets if necessary)

 Areas of Expertise

 Please check the areas in which you would be qualified (based on postgraduate education and training) and interested in giving an expert opinion:

List University and Postgraduate courses, which support your area of specialty:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

List all, which support your area of specialty:

 ________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

 Please answer the following questions:

 Has any license entitling you to practice chiropractic in any jurisdiction been refused, suspended, revoked, placed on probation, received sanctions or any other disciplinary action?
Yes _____ No _____

 Have you ever been convicted of or pled nolo contendere to a felony?
Yes _____ No _____

 Have you ever had malpractice or liability insurance coverage suspended, or a renewal refused or denied? Yes _____ No _____

Are there any malpractice judgments entered against you in any state or federal court, or have you agreed to any out-of-court settlements or malpractice claims? Yes _____ No _____

 Have you failed to report malpractice judgments and/or settlements to the Board of Chiropractic Examiners as required by the Colorado Chiropractic Practice Law C.R.S. 12-33-117(1)(j)?
Yes _____ No _____

 Have you participated as a witness or as a party in a malpractice case? Yes _____ No _____

 Have you testified in a civil case? Yes _____ No _____

 Have you ever been engaged as an expert witness or ever testified in a malpractice civil case as a witness or party? Yes _____ No _____

 Are you aware of any complaints filed against your license with the Colorado Chiropractic board? Yes _____ No _____

 Are you aware of anything which might be used to discredit you personally or your testimony if you are required to testify for the Board? Yes _____ No _____

 If you have answered "YES" to any of the above questions, please submit a written explanation with this application.

 Affidavit

 I agree that I shall refrain from entering into a doctor-patient relationship or accept any fee or payment for chiropractic care that is provided to a case complainant.

 ________________________________________ ______________________

Signature of Applicant Date