The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Phys Therapist Asst.
Albany, NY 12234-1000
CERTIFICATION OF PHYSICAL THERAPIST OR PHYSICAL THERAPIST
ASSISTANT LICENSURE IN ANOTHER STATE
If you are not licensed in another State or U.S. territory, do NOT use this form. You must use CGFNS or FCCPT to verify
your licensure status.
Complete Section 1. Enter your name as it appears on your Application (Form 1). Be sure to sign and date item 7.
2. Send this form with any fee required to the appropriate licensing authority of the state in which you are or have been licensed to complete
Section II and return this form directly to the Office of the Professions at the address at the end of this form.
NOTE: A separate Form 3 must be received by the Department from every state in which you are or have been licensed.
SECTION I: APPLICANT INFORMATION
SOCIAL SECURITY NUMBER
(Leave this blank if you do not have a U.S. Social Security Number)
PRINT FULL NAME
If not U.S.
If you took a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
If licensed by examination in the United States, indicate state or territory: ___________________________________________________________
Date license was issued: ________ / ________ / ________ License number: ________________________________________________________
I request and give my permission to the licensing authority listed in item 6 above to complete the information on this form and mail it to the New York
State Education Department and to release any other information required by the State Education Department in connection with my application for
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
CERTIFICATION OF LICENSURE IS TO BE MADE BY LICENSING AUTHORITY ON NEXT PAGE
FORM 3, PAGE 1 OF 2