Chiropractor Registration Application Form
※Type Classification
※First Name
Middle Name
※Last Name
Name in Japanese
姓
名
※If you know how to write your name in Japanese, please fill out this section.
Sex
※D.O.B. (Y/M/D)
年 月 日
※Face Profile Photo (attached image)
* If you cannot attach the file, please send it to us by email.
* Attached Files (jpeg, jpg, png, gif, pdf)
※Nationality
※Contact Address
※Telephone
- -
※Email Address
確認のためもう一度入力してください。
* If you don't own your email address, please write "office@chiroreg.jp".
Office Name
URL (Office)
Japanese Healthcare Licenses
※If you hold any Japanese healthcare licenses.
Other License
※Chiropractic Education
※Name of Chiropractic School
※Year of Graduation
年 月 日
※If you are unsure about your graduation month and day, please fill in the year and January 1.
※Have you ever been arrested or convicted for an offense or crime in Japan or another country?
※Have you ever been deported or refused entry on arrival to Japan or another country?
※Date of Application
年 月 日
※Copy of Degree (Attached File)
* If you cannot attach the file, please send it to us by email.
* Attached Files (jpeg, jpg, png, gif, pdf, zip)
※Additional Document (Attached File)
Please attach one of the following documentation with your application form;
1. a certificate providing you have passed the JCR Registration Exam
2. a certificate providing you have passed the NBCE Parts I & II
3. a copy of the overseas license to practice chiropractic
* If you cannot attach the file, please send it to us by email.
* Attached Files (jpeg, jpg, png, gif, pdf, zip)
Notes
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