Application For Licensure Form - 2000
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FOR OFFICE USE ONLY
Department of Community and Economic Development
Division of Occupational Licensing
State Physical Therapy and Occupational Therapy Board
P.O. Box 110806
Juneau, Alaska 99811-0806
Telephone: (907) 465-2580
E-mail: license@dced.state.ak.us
APPLICATION FOR LICENSURE AS:
Physical Therapist
Physical Therapy Assistant
By:
Credentials
Examination
Limited Permit
FEES:
Nonrefundable Application
$
50.00
Temporary Permit
$
50.00
Limited Permit
$
50.00
Physical Therapist License
$ 180.00
Physical Therapy Assistant
$ 130.00
Examination
$ 285.00
(Make exam fee payable to Federation of State Boards of
Physical Therapy
If applying by credentials or examination, do you need a temporary permit while awaiting permanent licensure?
Yes
No
Date you plan to begin working
It is illegal to begin employment without obtaining a license, temporary permit, or limited permit.
This application must be completed in full. If a section does not apply, write N/A in the space provided. Please
print or type.
Name:
Last
First
M.I.
Maiden
Mailing Address:
Street or Box
City
State
ZIP Code
Business Telephone:
Home Telephone:
Social Security Number:
Date of Birth:
Sex:
EDUCATION
Give complete names and addresses, and date diploma or degree was awarded for the following:
High School(s) attended:
Date Diploma or equivalent awarded:
College(s):
Date degree awarded:
08-4065 (Rev. 6/00)
– OVER –
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