CAGEN
Examination Policies:
Fees:
The examination fee is set annually by the board and is non-refundable and non-transferable.
Application:
Applications for the Board Certification Examination are included at the end
of this handbook.
Candidates may also obtain applications from the Board Web site at
http://www.acnb.org/application.html or from the ACNB at:
American Chiropractic Neurology Board, Inc.
2803 Williams Drive, Suite 105
Georgetown, Texas 78628
Or by telephone: (512) 863-2225 or FAX (512) 863-2233
Or via email: Secretary@acnb.org
MOST RECENT APPLICATION is illustrative of what will be required
for the next examination. See below.
American Chiropractic Neurology Board
Application for Board Examination
John C. Donofrio, D.C.,D.A.B.C.N., President
Sergio F. Azzolino, D.C., D.A.C.N.B. , Vice-President
Julia Allen, D.C.,D.A.C.N.B., Secretary
Gail Henry, D.C.,D.A.B.C.N., D.A.C.N.B. Acting Past President
Lucinda Harman, R.N., Ph.D., Treasurer, Public Member
- The application must be post-marked by the deadline. Completed, notarized
application
with passport photo attached. The photo MUST bear part of the notary/country seal. If outside the US- your application and photo must bear an official country seal. - Two recent passport photographs are required (no Polaroid’s). One is to be attached to your application form and the other is to be signed on the front, over the face, and attached by a paper clip to the upper right corner of the application, this loose photograph will be used to make your security identification tag.
- A photo copy of your Chiropractic Diploma.
- A current copy of your state license to practice Chiropractic.
- A copy of your post graduate neurology transcripts (300 hours) must be sent from the chiropractic college, university, institution, foundation or agency that provided the Neurology Diplomate education. You should request in writing, that the post graduate division of the college, agency, institution, or foundation forward the transcript directly to the Secretary of the ACNB. Please check with your institution’s syllabus for verification of the same. If your 300 hours will not be complete by the deadline please send transcripts before the exam date. Please be patient with your post-graduate division. Our experience has been very positive in obtaining transcripts in a timely manner.
- There are two (2) parts, a written examination and a practical examination.
Please verify whether taking all of the examination or a part. Please initial appropriate entry: - Registration fees: The fee for the entire examination is US $1500. There will be a fee of US $1500 for retaking the entire exam, US $850 for retaking part 1 (written) and US $650 for retaking part 2 (practical). The ACNB will accept a money order, cashiers check or personal check made payable to ACNB. Bank transfers will be accepted for an additional $37 fee. Credit card payments will be accepted. To request a bank transfer please contact Dr. Julia Allen (512)863-2225. The fees are non-refundable and non-transferable.
- Be sure your application is signed.
- We will respond by mail or E-mail when your
application is complete.
Please circle one
I request confirmation of the receipt of my application by Regular mail
Address__________________________________________
-or-E-mail
Email address__________________________________________ - 10. The ACNB will retain all records for three (3) years following the
examination. All examination
documents will be retained permanently in an electronic format. - The ACNB does not offer and is not affiliated with the Board Review.
Entire exam ____________________
Retake Part 1 (written) ___________
Retake Part 2 (practical)__________
Retake Both Part 1 & Part 2_____________ (written & practical)
If you are retaking the exam your transcripts are already in your previous file.
The ACNB does not discriminate for the purposes of application, examination,
continuing education, recertification or any other activity of the Board on
the basis of age, sex, religion, marital status, national origin, race, language,
or disability. All candidates and members are considered on the basis
of their skill and knowledge as practitioners based solely on their ability
to treat the consumer safely and effectively. The Board complies with
all applicable federal and state laws (ADA) with respect to certification and
recertification responsibilities. If
you have any special accommodation needs, please indicate specifically what
those needs are. If these needs are highly specialized, you may be required
to pay the cost for obtaining personnel or equipment to meet those needs. (Examples:
interpreters or adaptive electronic equipment)
__________________________________________
Address correspondence to:
Julia Allen D.C., D.A.C.N.B., Secretary of the Board
2803 Williams Drive, Suite 105,
Georgetown, TX 78628
Phone: 512/863-2225 Fax: 512/863-2233
Email: secretary@acnb.org
APPLICATION FOR EXAMINATION:
References
Please provide as a reference the names, addresses and phone numbers of two colleagues or other physicians not associated with your practice.
Reference: 1
__________________________________________
Reference: 2
__________________________________________
Disclaimer: Any examinee subsequently found not to have fulfilled all
ACNB requirements, either will not have his examination scored or, if already
scored, will be disallowed by ACNB.
I, _____________________________________, hereby certify that all foregoing information is accurate according to my knowledge.
__________________________________________
Applicant signature
__________________________________________
Date
ATTENTION:
Attach a recent passport photograph here. It must bear a part of a notary
stamp.
(raised or ink stamp)
Sworn to and subscribed before me this _______day of ___________, ____ by __________________________________________
who personally appeared before me and who is personally known to me, or has produced identification, and who acknowledged before me that the facts and statements herein are true and accurate and whose photograph attached is that of the signee.
Notary Public __________________________________________
State of __________________________________________
County of __________________________________________
My commission expires:
General Information (Please print legibly)
Name: SSN:
__________________________________________
E-mail Address__________________________________________
Please print mailing address for all correspondence pertaining to this application.
Address:
Street__________________________________________
City__________________________________________
State__________________________________________
Postal Code (zip)__________________________________________
Country__________________________________________
Telephone: ___________________________(Fax) ______________________________
Education:
Undergraduate:
Institution_________________________________Degree____________
Institution_________________________________Degree____________
Institution_________________________________Degree____________
Graduate:
Institution_________________________________Degree____________
Institution_________________________________Degree____________
Professional:
Institution_________________________________Degree____________
Institution_________________________________Degree____________
Post Graduate Neurology Training:
Institution_________________________________Degree____________
Institution_________________________________Degree____________
Licensure
In what states/provinces/countries are you licensed to practice Chiropractic?
__________________________________________
Has your license to practice Chiropractic ever been restricted or revoked
in any state?
Yes____________ No___________
If yes please explain the circumstances and reasons.
__________________________________________
Have you ever been convicted of a felony?
Yes____________ No___________
If yes please explain the circumstances and reasons.
__________________________________________
Print a PDF of ACNB Application for Board Examination