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By my signature below, I certify that I am a chiropractic physician licensed by: ☐ Oregon Board of Chiropractic Examiners. Certifying Statement--Read the certifying statement and then sign and date your application.4-Page Application. (cont'd). Completed a minimum of 100 hours of postgraduate education in the Certified Chiropractic Sports Physicians® program at an accredited chiropractic college. Please complete form and return the fees (certified check or money order) to the address below. Also print legibly or type the information. 030) "Certificate" means a current certificate as a chiropractic assistant. Certifying Statement--Read the certifying statement and then sign and date your application. 4-Page Application. (cont'd). Must complete this application to enroll in the Medicare program and receive a Medicare billing number.