Physical Therapy Form 3 - Certification Of Physical Therapist Or Physical Therapist Assistant Licensure In Another State Page 2

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SECTION II : CERTIFICATION OF LICENSURE
INSTRUCTIONS TO LICENSING AUTHORITY:
Please complete this section and return this form directly to the Office of the Professions at the address
at the end of this form. This form will not be accepted if returned by the applicant. Attach additional sheets if necessary.
1.
Name of applicant
: ________________________________________________________________________________________________
2.
Profession in which applicant is licensed in your jurisdiction:
Physical Therapy
Physical Therapist Assistant
3.
License number: ___________________________________________ Date of licensure: ________ / ________ / ________
Mo.
Day
Yr.
4.
Jurisdiction issuing original license or certification: ____________________________________________________________
5.
Is the individual currently licensed or registered?
Yes
No If Yes, Date of expiration:
________ / ________ / ________
Mo.
Day
Yr.
6.
Please indicate if the license was issued under any of the following special conditions (check all that apply):
Endorsement of licensure in another jurisdiction (please identify: ______________________________________)
Waiver of examination
Waiver of education
Other (please attach explanation)
7.
If the license was issued based on an examination, please indicate the examination title, date and score (eg. National Physical
Therapy Examination; PES/ASI Examination; State Examination, etc.):
Examination title _____________________________________________
Date _____ / _____ / _____ Score ________________
8.
Did the issuance of this license involve any practice limitations?
Yes
No
9.
Was there ever any disciplinary action against this license?
Yes
No
(If the answer to question 5 or 6 is yes, please describe in detail and attach.)
10. Are there any disciplinary charges pending against this license or has he/she surrendered a license to
Yes
No
avoid disciplinary charges?
CERTIFICATION
I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this
form. I further certify that, other than those listed above or attached, this licensing authority has never taken any disciplinary action
against this person and that, in so far as the licensing authority has knowledge, there have been no charges preferred nor has any
information been presented relating to any question of unprofessional or immoral conduct .
Signature __________________________________________________________________________ Date _______ / _______ / _______
Title _______________________________________________________________________
Agency _____________________________________________________________________
Address ____________________________________________________________________
(LICENSING AUTHORITY
____________________________________________________________________________
SEAL)
Telephone number ____________________________ Fax ___________________________
E-mail _____________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Physical
Therapy Unit, 89 Washington Avenue, Albany, New York 12234-1000
TO
February 2003
FORM 3, PAGE 2 OF 2

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