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APPLICATION FOR LICENSURE AS A PHYSICAL THERAPIST OR PHYSICAL THERAPIST'S ASSISTANT
State Form 9111 (R12 / 2-06) Approved by State Board of Accounts, 2006

PHYSICAL THERAPY COMMITTEE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected]

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. FOR OFFICE USE ONLY
Application fee Date fee paid (month, day, year) Receipt number Application number License number Temporary permit fee Date fee paid (month, day, year) Receipt number Temporary permit number Temporary permit issuance date (month, day, year)

APPLICANT
Attach two (2) passport type quality photographs of yourself taken within the last eight weeks. Please sign each photo at the bottom. Negatives and Polaroids are not acceptable.

License issuance date (month, day, year)

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION

Name of applicant (last, first, middle, maiden) Address (number and street or rural route) (City, state, and ZIP code) T elephone number (daytime) Date of birth (month, day, year)

Social Security number*

Email address Birth place

(

)

BASIS FOR LICENSURE
Please check appropriate box

Examination
Please check appropriate box

Endorsement Physical Therapist's Assistant Yes No (If "Yes", please give details as to where and when)

Physical Therapist

Have you previously filed an application for licensure/certification by examination or endorsement as a Physical Therapist or Physical Therapist's Assistant in Indiana or any other state? Have you previously taken the licensure or certification examination for Physical Therapy or Physical Therapists Assistant? (If yes, please list date and place)

Yes Yes

No No (If "Yes", please give details as to where and when) TEMPORARY PERMIT

Have you previously failed the licensure or certification examination in Indiana or any other state?

Do you desire a temporary permit?

Yes
Name of school Location

No
Date of graduation (month, day, year)

PHYSICAL THERAPIST / PHYSICAL THERAPIST'S ASSISTANT DEGREE GRANTED BY

UNDERGRADUATE AND GRADUATE TRAINING NAME OF SCHOOL LOCATION FROM TO (month, year) (month, year) DEGREE

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LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED OR CERTIFIED TO PRACTICE ANY REGULATED HEALTH PROFESSION STATE TYPE OF LICENSE OR CERTIFICATE NUMBER DATE ISSUED (month, day, year) CURRENT STATUS

PLACES OF EMPLOYMENT SINCE GRADUATION NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES

DATE (month, day, year)

PLACES YOU HAVE LIVED SINCE GRADUATION GENERAL LOCATION

DATE (month, day, year)

If your answer is "Yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location and date. If malpractice, provide name(s) of plaintiff(s). Letters from attorneys or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license, certification or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied licensure, registration or certification in any state (including Indiana) or country? 3. Are you now, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, plead guilty to or nolo contendre to any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations? 6. Have you ever been admonished, censored, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

Yes Yes Yes Yes Yes

No No No No No

Yes Yes

No No

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AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for physical therapy licensure or physical therapists assistant certification. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application and I hereby specifically release the Agency and the Committee from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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