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Supervisor'S Affidavit - State Of Maine Department Of Professional And Financial Regulation

S T A T E O F M A I N E

E P A R T M E N T O F

R O F E S S I O N A L

A N D

I N A N C I A L

E G U L A T I O N

BOARD OF EXAMINERS IN PHYSICAL THERAPY

S T A T E H O U S E S T A T I O N

04333-0035

A U G U S T A

M A I N E

:(207)624-8603 – F

:(207)624-8666

E L

A X

SUPERVISOR’S AFFIDAVIT

Pursuant to 32 MRS § 3113-B

Graduate Physical Therapist’s Name:

Supervisor’s Name:

License Number of Applicant:

Supervisor’s Tel:

Supervisor’s Email:

Facility Name:

Facility Address:

Facility City:

Facility State:

Facility Zip Code:

Facility Telephone:

I, the above named supervisor, will assume responsibility and liability for the graduate physical

therapist/assistant who is awaiting results of the computerized physical therapist/physical therapist

assistant examination. I will immediately notify the Board of Examiners in Physical Therapy of any

change in supervision of this employee prior to publication of the examination results.

Supervisor’s Signature:

Pursuant to 32 MRS §3113-B you must be a graduate physical therapist of physical therapist assistant

in order to be approved to work while you are awaiting to take your examination. A copy of your tran-

script must be submitted with this form. The Board will send an approval letter to the applicant and

supervisor regarding the approval or denial of the exemption to practice.

PLEASE RETURN COMPLETED FORM TO THE APPLICANT

Upon review and acceptance a copy will be returned to both the PT graduate and the above

named supervisor

For office use only

Accepted

Not Accepted – Reason: ____________________________

Action Date: _________________

Staff Signature: ________________________________

Date Copy Sent to PT and Supervisor: ________________

01402A4390012

04/2014

UBLISHED UNDER APPROPRIATION

EVISED

35 S

, A

ME 043333

TATE

OUSE

TATION

UGUSTA

EBSITE

WWW

MAINE

GOV

PROFESSIONALLICENSING

Supervisor'S Affidavit - State Of Maine Department Of Professional And Financial Regulation

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