Physical Therapy Form 4 "Endorsement Applicant Professional Experience Record" - New York

What Is Physical Therapy Form 4?

This is a legal form that was released by the New York State Education Department - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2012;
  • The latest edition provided by the New York State Education Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Physical Therapy Form 4 by clicking the link below or browse more documents and templates provided by the New York State Education Department.

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Download Physical Therapy Form 4 "Endorsement Applicant Professional Experience Record" - New York

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The University of the State of New York
Physical Therapy
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 4
Division of Professional Licensing Services
www.op.nysed.gov
Endorsement Applicant Professional Experience Record
This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy
issued in another jurisdiction.
To qualify for licensure by endorsement, you must have at least three years of professional experience in the practice of physical
therapy acceptable to the State Board for Physical Therapy. Your professional experience must follow your initial licensure and be
within the seven years immediately preceding application for licensure by endorsement.
Applicant Instructions
1. Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to
sign and date item 8.
2. To enable the Office of the Professions to receive documentation of your experience, you must also complete Section I of Form 4A and
forward the entire form to each colleague you list on page 2 of this form.
1
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2
Birth Date Month
Day
Year
3
Print Name as It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Telephone/E-mail
Daytime phone
E-mail Address
(please print clearly)
Area Code
Phone
6
Give any other names by which you have been known: ________________________________________________________________
Physical Therapy Form 4, Page 1 of 2, December 2012
1.
2.
3.
4.
5.
8.
The University of the State of New York
Physical Therapy
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Form 4
Division of Professional Licensing Services
www.op.nysed.gov
Endorsement Applicant Professional Experience Record
This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy
issued in another jurisdiction.
To qualify for licensure by endorsement, you must have at least three years of professional experience in the practice of physical
therapy acceptable to the State Board for Physical Therapy. Your professional experience must follow your initial licensure and be
within the seven years immediately preceding application for licensure by endorsement.
Applicant Instructions
1. Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to
sign and date item 8.
2. To enable the Office of the Professions to receive documentation of your experience, you must also complete Section I of Form 4A and
forward the entire form to each colleague you list on page 2 of this form.
1
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
2
Birth Date Month
Day
Year
3
Print Name as It Appears on Your Application for Licensure (Form 1)
Last
First
Middle
4
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Telephone/E-mail
Daytime phone
E-mail Address
(please print clearly)
Area Code
Phone
6
Give any other names by which you have been known: ________________________________________________________________
Physical Therapy Form 4, Page 1 of 2, December 2012
9.
10.
7
List the colleague(s) who will verify your professional experience in the practice of physical therapy. The colleague(s) listed
must have knowledge of your professional practice of physical therapy totaling at least three years. All listed experience must
follow your initial licensure and be within the seven years immediately preceding application for licensure by endorsement.
Dates of Experience
Assigned
Name of Colleague and Address of Experience Setting
Number
From
To
1
2
3
4
5
6
7
8
Attestation
I declare and affirm under penalty of perjury that the statements made in the foregoing application, including accompanying
statements are true, complete and correct. I understand that any false or misleading information in, or in connection with, my
application may be cause for denial of qualification and may lead to a filing of charges of professional misconduct.
_________________________________________________________________________________ _______ / _______ / _______
Applicant’s Signature
mo.
day
yr.
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Physical Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Physical Therapy Form 4, Page 2 of 2, December 2012
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