Physical Therapy Form 3 - Certification Of Physical Therapist Or Physical Therapist Assistant Licensure In Another State
ADVERTISEMENT
1
2FORM 3
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
(check one)
Office of the Professions
Physical Therapist
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
APPLICANT INSTRUCTIONS
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.
1.
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
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT FULL NAME
Last
First
Middle
MAILING
4
Street
ADDRESS
City
State
Zip Code
Province/Country
If not U.S.
5
If you took a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
6
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
7
State Education Department and to release any other information required by the State Education Department in connection with my application for
licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
CERTIFICATION OF LICENSURE IS TO BE MADE BY LICENSING AUTHORITY ON NEXT PAGE
February 2003
FORM 3, PAGE 1 OF 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 3 - Certification Of Out-of-state Licensure And Examination Grades - The State Education Department, The University Of The State Of New York
Legal
Physical Therapy Form 4a - Certification Of Professional Experience For Endorsement Applicants - New York The State Education Department
Legal
Physical Therapy Form 2 - Certification Of Professional Education - New York The State Education Department
Legal
Form 62a378 - Report Of Mobile Homes And Recreational Vehicles Not Registered In This State
Financial
Massage Therapy Form 3 - Verification Of Out-of-state Licensure Or Registration - New York The State Education Department
Legal
Ophthalmic Dispensing Form 3 - Certification Of Ophthalmic Dispensing License In Another Jurisdiction - New York The State Education Department
Legal
Related Categories
Parent category: Legal