Free 52563.FH11 - Indiana

APPLICATION FOR REPEAT EXAMINATION FOR PHYSICAL THERAPISTS AND PHYSICAL THERAPISTS ASSISTANTS
State Form 52563 (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]

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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.

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER CERTIFICATION NUMBER DO NOT WRITE ABOVE THIS LINE

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

Please check one:

Physical Therapy

Physical Therapist Assistant

APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City Telephone number (daytime) State Email address Date of graduation (month, day, year) ZIP code Social Security number *

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Name of school

If your answer is Yes to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including the location, date and disposition. If malpractice, provide name of plaintiff. Falsification of any of the following is grounds for permanent revocation of the license 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 being or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty 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? If you answered Yes on your original application and submitted documentation, please check here: You only need to submit additional information if circumstances have changed since you last submitted an explanation regarding these questions. 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

No No No No

Yes

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 or the Physical Therapy Committee any files, documents, records or other information pertaining to the undersigned requested by the Agency or Committee, or any of its authorized representatives in connection with processing my application for physical therapy or physical therapists assistant licensure. 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 and the Physical Therapy Committee 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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