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The University of the State of New York

Physical Therapy

Assigned No.

THE STATE EDUCATION DEPARTMENT

(From Form 4)

Office of the Professions

Form 4A

Division of Professional Licensing Services

__________

Certification of Professional Experience for

Endorsement Applicants

This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy

issued in another jurisdiction.

Applicant Instructions

Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 7.

Send this entire form to your colleague to complete Section II. The colleague must return both pages of the form directly to the Office of

the Professions at the address at the end of the form. If additional copies are needed, you may photocopy this form. This form will not

be accepted if returned by the applicant.

Section I: Applicant Information

Social Security Number

Birth Date Month

Day

Year

(Leave this blank if you do not have a U.S. Social Security Number)

Print Name As It Appears On Your Application for Licensure (Form 1)

Last

First

Middle

Mailing Address

(You must notify the Department promptly of any address or name changes.)

Line 1

Line 2

Line 3

City

State

Zip Code

Country/

Province

Name at time of employment (if different from above): _________________________________________________________________

Name of colleague: ____________________________________________________________ Assigned number from Form 4 _______

I practiced licensed physical therapy as defined below:

“The Practice of physical therapy is defined as the evaluation, treatment or prevention of disability, injury, disease, or other condition of

health using physical, chemical, and mechanical means including, but not limited to heat, cold, light, air, water, sound, electricity,

massage, mobilization, and therapeutic exercise with or without assistive devices, and the performance and interpretation of tests and

measurements to assess pathophysiological, pathomechanical, and developmental deficits of human systems to determine treatment,

and assist in diagnosis and prognosis.”

Jurisdiction where I practiced physical therapy: _______________________________________________________________________

Date of licensure: _______ / ______ / _______ License number ____________________

mo.

day

yr.

I request and give my permission to the individual listed in item 6 to complete Section II of this form and mail it to the New York State

Education Department at the address at the end of this form, and to release any other information requested by the State Education

Department in connection with my application for licensure. I also declare and affirm under penalty of perjury that the statements made

in this application, including accompanying documents, are true, complete and correct. I understand that any false or misleading

information in, or in connection with, my application may be cause for denial or loss of licensure and may result in criminal prosecution.

_____________________________________________________________________________ Date ________ / _______ / ________

Signature of applicant

mo.

day

yr.

Physical Therapy Form 4A, Page 1 of 2, December 2012

Physical Therapy Form 4a - Certification Of Professional Experience For Endorsement Applicants - New York The State Education Department

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