Physical Therapist Or Physical Therapist Assistant General Response Form Page 3

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Page 3 of 3 (11/15)

NAME OF PT OR PTA ______________________________

LICENSE NO __________________________

CERTIFICATION

 I certify that the information provided is a true and complete record of my PDR credits earned under Activity Code 3

and/or 4.

*Unsigned forms will be considered incomplete.

__________________________________________________

____________________________________

Signature of Physical Therapist or Physical Therapist Assistant

License Number

__________________________________________________

_____________________________________

Print or Type Name

Date

The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability, or political

beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency