Philippine Institute of Traditional and Alternative Health Care

PITAHC Bldg., Matapang St., East Ave. Medical Center Cmpd. PITAHC
Brgy. Central, Quezon City Tel. No. (02)376-3067 / (02)376-3068

CHIROPRACTIC APPLICATION
FORM
Name: _______________ __________________ _________________
(Last) (First) (Middle)
Passport size
Photo Date of Birth ______________ Place of Birth ____________
(dd/mm/yyyy)

Citizenship: Filipino Dual Citizenship ___________________

(Specify Country of Nationality)

Non-Filipino ___________________________________________
(Passport Number and Issuing Country)++++

Immigration/Visa Status ___________________________________

Are you a member of the Association of Professional Chiropractors of the Yes No

Philippines, Inc, (APCPI)?

If No, would you like to receive information on APCPI membership? Yes No

Section A: Contact Information

Residential Address: _______________________________________________

Business Address:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

Email: _______________________________ Landline/Mobile: ________________

Business Landline: _____________________ Business Mobile: ________________
PITAHC Registration No.: _________________Valid Until: _____________________

Applicant’s Signature ____________________

 Philippine Institute of Traditional and Alternative Health Care
PITAHC Bldg., Matapang St., East Ave. Med. Cntr. Cmpd. PITAHC
Brgy. Central, Quezon City Tel. No. (02)376-3067 / (02)376-3068

Section B: Educational Background (Please Indicate College/University level or higher

only)

Degree Course Name of Institution Date of Completion

Section C: Licensure Examination

Nature of Examination Date Taken Rating

Section D: Health Care Related Work Experience (Please list from newest to oldest)

Nature of Work Experience/Title Company/Clinic/Office Name Date of Employment

Section E: Specialties (i.e., Certification and/or Diplomates)

Nature of Specialty Certification Number Date Certified (From – To)

Applicant’s Signature ____________________

 Philippine Institute of Traditional and Alternative Health Care
PITAHC Bldg., Matapang St., East Ave. Med. Cntr. Cmpd. PITAHC
Brgy. Central, Quezon City Tel. No. (02)376-3067 / (02)376-3068

Section F: Law Violation

F1. Have you ever been convicted of any crime or violation Yes No
of any law, decree, ordinance or regulation by any court
in the Philippines or any other country?

If Yes, please give details: _____________________________________________

_____________________________________________

Section G: Consent

I consent to the National Certification Committee for Chiropractic (NCCC) and/or PITAHC to make inquiries of,
and exchange information with, the authorities of any Country, State or Territory regarding my practice as a health
practitioner or any other matters relevant to this application.

I acknowledge that the National Certification Committee for Chiropractic (NCCC) and/or PITAHC may validate
documents provided in support of this application as evidence of my identity and/or immigration status.

I declare that I will comply with all relevant legislation, National Certification Committee for Chiropractic (NCCC)
and/or PITAHC Standards, Codes and Guidelines.

I HEREBY CERTIFY that the information and/or statements in this application including the documents submitted
in support thereof are all true and correct of my knowledge, and that I am fully aware that any false information or
statement and/or any omission of any pertinent information in this application or in its attachments, shall render me
liable for administrative sanction and/or denial and/or revocation of PITAHC Registration/Certification

__________________________________ ____________
Signature of Applicant Over Printed Name Date

Left Thumbmark Right Thumbmark

PITAHC/NCCC Received by ______________________

Date: _______________
 AFFIDAVIT OF UNDERTAKING

Republic of the Philippines

City/Municipality of ______________) s.s
Province _______________________)

I, _______________________, (indicate Nationality), of legal age with address at

_____________________________, after having been sworn to in accordance with law hereby
depose and state THAT:

1. I am an applicant for Chiropractic certification pursuant to the PITAHC established

guidelines, PITAHC Circular No. 01 series of 2010 “Guidelines on the National
Certification of Chiropractic”;
2. I attest to the truth, accuracy and genuineness of all the information, documents
and records contained and attached to this application and that I shall be liable for
any misrepresentation, fraudulent declaration and all its consequences;
3. I am executing this affidavit as a proof of good faith in complying with the
requirements for securing the abovementioned certificate.

AFFIANTS SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this _______day of

___________________ 2015 in ______________________.

Signature over printed name

Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this ___ day of ____________
2015__ at _____________ City, affiant exhibited to me his (any government issued ID) issued on
______________ at ______________.

Doc. No. _________

Page No. _________
Book No._________
Series No. ________

AFFIDAVIT OF UNDERTAKING

Republic of the Philippines

City/Municipality of ______________) s.s
Province _______________________)

I, _______________________, Filipino, of legal age with address at

_____________________________, after having been sworn to in accordance with law hereby
depose and state THAT:

1. I am an applicant for Chiropractic certification pursuant to the PITAHC established

guidelines, PITAHC Circular No. 01 series of 2010 “Guidelines on the National
Certification of Chiropractic”;
2. I attest to the truth, accuracy and genuineness of all the information, documents
and records contained and attached to this application and that I shall be liable for
any misrepresentation, fraudulent declaration and all its consequences;
3. I am executing this affidavit as a proof of good faith in complying with the
requirements for securing the abovementioned certificate.

AFFIANTS SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this _______day of

___________________ 2015 in ______________________.

Signature over printed name

Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this ___ day of ____________
2015__ at _____________ City, affiant exhibited to me his (any government issued ID) issued on
______________ at ______________.

Doc. No. _________

Page No. _________
Book No._________
Series No. ________