CCA Level I - Application for CCA Level I Renewal (21 NCAC 10 .0213)

Renewal Requirements CCA Level I – Clinical

A certificate holder seeking to renew shall submit evidence that the applicant has completed six hours of Board-approved continuing education.

If you do not recall your Clinical Certificate Number please click on this link to search for it: Search/Verify License or Certificate Holder.

Certified Chiropractic Assistant Level I – Clinical Certificate Number*
I. Personal Information
Name*
First Middle Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Primary Telephone*
Cell phone
Email*
NOTE: This email should be unique to you and checked regularly. This will be used for your login and for communication from the board.
Date of Birth*
Month
Day
Year
II. Personal History
Have you been convicted of a felony?*
- Yes
- No
Please identify felony, give date of conviction, county and state where convicted*
Are there any pending criminal charges against you?*
- Yes
- No
Please identify all charges*
Are you addicted to or dependent upon alcohol or any other drug?*
- Yes
- No
Please explain
III. Employment Information
Date Employed
Month
Day
Year
Name of Chiropractic Office/Clinic
Supervising DC
Office email address
Telephone
Address
Street Address Address Line 2 City State ZIP Code
IV. Continuing Education
Unless provided by another source such as the education provider, please upload evidence of continuing education completion. These documents can also be faxed to us at 704-793-1385 or emailed to john@ncchiroboard.com.
Upload Document
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 256 MB.
Consent*
By submitting this application, I affirm that the information contained herein is accurate and complete.
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NOTE:
Once you have successfully submitted this form you will be redirected Make a Payment page to complete your renewal.