Application For Licensure Form - 2000 Page 2
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4PROFESSIONAL DATA
List the state(s) in which you hold or have ever held a license or temporary permit to practice physical
therapy:
State:
License No.
Date Issued:
Expiration Date:
State:
License No.
Date Issued:
Expiration Date:
State:
License No.
Date Issued:
Expiration Date:
State:
License No.
Date Issued:
Expiration Date:
State:
License No.
Date Issued:
Expiration Date:
State:
License No.
Date Issued:
Expiration Date:
List any states in which you took a physical therapy examination:
Circle either Passed
or Failed, as appropriate
a. State:
Exam Administered by:
Exam Date:
Passed Failed
b. State:
Exam Administered by:
Exam Date:
Passed Failed
c. State:
Exam Administered by:
Exam Date:
Passed Failed
If credentials are not approved by the board, do you wish to take the national physical therapy examination for
Physical Therapy in order to be licensed in Alaska?
Yes
No
If applying for a Temporary Permit by examination, what is the name and Alaska license number of your supervising
therapist?
Name:
License No.
Mailing Address:
State:
ZIP Code:
OCCUPATIONAL DATA
In chronological order, from most recent to most remote, list all relevant or related professional positions held.
Provide names of employers, addresses, zip code, telephone numbers, positions held, duties, responsibilities, and
name of direct supervisor(s):
Expected Place of Employment in Alaska:
Mailing Address:
City:
State:
ZIP Code:
Telephone:
Expected Beginning Date of Employment:
1. Name of Employer:
Dates: From:
To:
Employer Address:
Employer Telephone No.:
Name of Supervisor:
Location of Practice if Different From Employer:
Position Held by Applicant:
Duties and Responsibilities:
08-4065 (Rev. 6/00)
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