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12STATE OF DELAWARE
T
: (302) 744-4500
ELEPHONE
C
B
ANNON
UILDING
F
: (302) 739-2711
AX
861 S
L
B
., S
203
ILVER
AKE
LVD
UITE
EXAMINING BOARD OF PHYSICAL THERAPISTS AND
W
:
.
.
EBSITE
DPR
DELAWARE
GOV
D
, D
19904-2467
OVER
ELAWARE
ATHLETIC TRAINERS
customerservice.dpr@state.de.us
EMAIL:
APPLICATION FOR LICENSURE AS A PHYSICAL THERAPIST OR PHYSICAL THERAPIST ASSISTANT
TYPE OF APPLICATION
1. Select type of license you are applying for:
Physical Therapist – Show where you received your education (check one):
I received my Physical Therapy education in the U.S. or a U.S. territory.
I received my Physical Therapy education outside the U.S. or a U.S. territory.
Do you hold an active Delaware Physical Therapist Assistant license? Yes
No
If yes, enter your license
number: J2 - _______________
Physical Therapist Assistant
I received my Physical Therapy Assistant education in the U.S. or a U.S. territory.
I received my Physical Therapy Assistant education outside the U.S. or a U.S. territory.
2. Check the item that describes your situation (check one):
Examination –
I need to take the national examination.
I have already passed the national examination but I do not hold a current license in any
jurisdiction. Skip to the
section.
IDENTIFYING AND CONTACT INFORMATION
Reciprocity – I hold a current license in another jurisdiction. Skip to the
IDENTIFYING AND CONTACT
section.
INFORMATION
Reinstatement – I previously held a Delaware license that lapsed less than five years ago. My Delaware license
number was J___ - _______________. Skip to the
section.
IDENTIFYING AND CONTACT INFORMATION
Reapplication – I previously held a Delaware license that lapsed more than five years ago. My Delaware license
number was J___- _______________. Skip to the
section.
IDENTIFYING AND CONTACT INFORMATION
•
If you checked Reciprocity, enclose a copy of proof that you have completed two hours of training in
ethics related to the practice of physical therapy.
•
If you checked Reinstatement or Reapplication, submit proof that you have completed 3.0 continuing
education units (CEUs) during the previous 24 months.
3. Are you applying for a Temporary license while awaiting your exam scores? Yes
No
If yes, enter the following
information about your Delaware-licensed supervising Physical Therapist:
Name: ______________________________________________ Delaware License Number: J1 - ________________
Place of Employment: _________________________________________________ Phone: ____________________
Arrange for the Board office to receive a
Statement of Supervising Physical Therapist or Athletic Trainer –
Temporary License
completed and signed by your supervising Physical Therapist, sent directly to the Board
office by supervisor.
IDENTIFYING AND CONTACT INFORMATION
4. Full Name: ____________________________________ ______________________________ _________________
Last/Family
First
Middle
5. Other Names Used: None
_______________________ ___________________________ ___________________
(Include maiden, former married names and alternate spellings.)
Revised 6/2016
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