Application For Licensure Form - 2000 (Page 4 of 4) in pdf

PROFESSIONAL FITNESS - (If you answer “yes” to any question, please explain in full on a separate

affidavit and enclose applicable legal documentation.)

YES

1. Have you ever been disciplined by any state board or Physical Therapy Association

concerning violation of the Physical Therapy Practice Act or unethical conduct? ..................

2. Have you ever been denied a license or had a license revoked, suspended, restricted,

limited, or otherwise acted upon? .............................................................................................

3. Have you ever been denied the privilege of taking an examination before any state

Physical Therapy Board?...........................................................................................................

4. Have you ever been convicted of a felony or misdemeanor, other than minor traffic

violations, under the laws of local, state, or federal jurisdiction of the United State or any

other country?.............................................................................................................................

5. Have you ever been convicted of a violation of any federal or state narcotic laws? .................

6. Have you ever had any malpractice settlements or judgments paid in your behalf? ................

7. Within the last five years, have you been treated for, or hospitalized for, emotional or

mental illness, drug addiction or alcoholism? ............................................................................

8. Within the last five years, have you been addicted to, or excessively used, or misused,

alcohol, narcotics, barbiturates or habit-forming drugs?............................................................

Please be aware that all information on this application will be available to the public, unless required to be kept

confidential by state or federal law.

I hereby certify that the information in this application is true and correct to the best of my knowledge. I understand

that any false information may result in failure to obtain licensure as a physical therapist, or physical therapy

assistant in Alaska, or subsequent revocation of my license.

Position recent

Signature of Applicant

head/shoulder

photo here.

Notary seal must overlie

portion of photograph

SUBSCRIBED AND SWORN before me, a Notary Public, in and for the State of

this

day of

, 20

Notary Public

My Commission Expires:

NOTE: If you are a foreign-trained therapist, do not use this application; you must contact the division for the

correct application.

08-4065 (Rev. 6/00)

Application For Licensure Form - 2000 Page 4