Physical Therapy Form 2 - Certification Of Professional Education - New York The State Education Department
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1
2FORM 2
(check one)
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
PHYSICAL THERAPIST
89 Washington Avenue
Albany, NY 12234-1000
PHYSICAL THERAPIST
ASSISTANT
CERTIFICATION OF PROFESSIONAL EDUCATION
APPLICANT INSTRUCTIONS
1.
If your professional program is not accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the
American Physical Therapy Association (APTA), (most schools located outside the United States are not accredited) do not use this
form. See ‘Education Requirements’ for further instructions.
2.
If you graduated from a New York State registered licensure-qualifying program or an APTA accredited program, complete Section I in ink.
Enter your name as it appears on your Licensure Application (Form 1). Be sure to sign and date item 8.
3.
Send this form to the institution you attended and ask the registrar to complete the appropriate parts of Section II of this form. Be sure to
include any fee required. The institution completing Section II must forward it directly to the Office of the Professions at the address at the
end of this form. The Office of the Professions will not accept this form unless it is submitted directly by the institution.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
PRINT FULL NAME EXACTLY AS IT APPEARS ON YOUR LICENSURE APPLICATION (FORM 1)
3
Last
First
Middle
4
MAILING ADDRESS
(You must notify the Department promptly of any address or name changes.)
Street
City
State
Zip Code
Province/Country
If not U.S.
5
Print name under which your degree/diploma was awarded: __________________________________________________________________
6
Professional School attended: _________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
7
Title of diploma or degree: _________________________________________ Date diploma or degree was awarded: _______ / _______ / ______
I request and give my permission to the institution(s) listed in item 6 above to provide any information requested, including that requested on this
8
form, to the New York State Education Department.
__________________________________________________________________________
________________________________
Applicant's signature
Date
FORM 2, PAGE 1 OF 2
February 2003
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