Licensure By Examination To Practice As A Physical Therapist Or Physical Therapist (Page 3 of 3) in pdf

Licensure By Examination To Practice As A Physical Therapist Or Physical Therapist Page 3

Page 3 of 3

EDUCATIONAL AUTHORIZATION FORM

COMMONWEALTH OF VIRGINIA

VIRGINIA BOARD OF PHYSICAL THERAPY

DEPARTMENT OF HEALTH PROFESSIONS

Perimeter Center, 9960 Mayland Drive, Suite 300 - Henrico, Virginia 23233-1463

(804) 367-4674 (phone) website:

Submit this form to your school for verification that you are within 60 days of completion of degree

requirements and instruct them to return the completed form directly to the Virginia Board of

Physical Therapy.

NOTE TO APPLICANTS: This does not replace official transcripts for the application

process. This form is required if you have not yet received your degree but are within 60

days of fulfilling the requirements. Licensure will not be issued until official transcripts are

received confirming the degree. The Board will not release the test scores until the official

transcript is received.

(For graduates of approved programs only)

It is hereby certified that __________________________________________________________

Name of Applicant

is enrolled in _____________________________________________ on ______________________

Course of Study

Date

and is within 60 days of completing the degree requirements of ___________________________

Degree

from _____________________________________________________________________________

Name of Institution

on __________________.

Date

_____________________________________

Signature of Dean or Department Head

Completed form must be mailed to:

Virginia Board of Physical Therapy

Perimeter Center

9960 Mayland Drive, Suite 300

Henrico, Virginia 23233-1463

Rev Form: 3/29/2013

Licensure By Examination To Practice As A Physical Therapist Or Physical Therapist Page 3