Physical Therapy Form 3 "Certification of Physical Therapist or Physical Therapist Assistant Licensure in Another State" - New York

What Is Physical Therapy Form 3?

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 February 1, 2003;
  • 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 3 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 3 "Certification of Physical Therapist or Physical Therapist Assistant Licensure in Another State" - New York

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FORM 3
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
(check one)
Office of the Professions
Physical Therapist
Division of Professional Licensing Services
89 Washington Avenue
Phys Therapist Asst.
Albany, NY 12234-1000
CERTIFICATION OF PHYSICAL THERAPIST OR PHYSICAL THERAPIST
ASSISTANT LICENSURE IN ANOTHER STATE
APPLICANT INSTRUCTIONS
If you are not licensed in another State or U.S. territory, do NOT use this form. You must use CGFNS or FCCPT to verify
your licensure status.
1.
Complete Section 1. Enter your name as it appears on your Application (Form 1). Be sure to sign and date item 7.
2. Send this form with any fee required to the appropriate licensing authority of the state in which you are or have been licensed to complete
Section II and return this form directly to the Office of the Professions at the address at the end of this form.
NOTE: A separate Form 3 must be received by the Department from every state in which you are or have been licensed.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT FULL NAME
Last
First
Middle
MAILING
4
Street
ADDRESS
City
State
Zip Code
Province/Country
If not U.S.
5
If you took a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
6
If licensed by examination in the United States, indicate state or territory: ___________________________________________________________
Date license was issued: ________ / ________ / ________ License number: ________________________________________________________
I request and give my permission to the licensing authority listed in item 6 above to complete the information on this form and mail it to the New York
7
State Education Department and to release any other information required by the State Education Department in connection with my application for
licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
CERTIFICATION OF LICENSURE IS TO BE MADE BY LICENSING AUTHORITY ON NEXT PAGE
February 2003
FORM 3, PAGE 1 OF 2
FORM 3
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
(check one)
Office of the Professions
Physical Therapist
Division of Professional Licensing Services
89 Washington Avenue
Phys Therapist Asst.
Albany, NY 12234-1000
CERTIFICATION OF PHYSICAL THERAPIST OR PHYSICAL THERAPIST
ASSISTANT LICENSURE IN ANOTHER STATE
APPLICANT INSTRUCTIONS
If you are not licensed in another State or U.S. territory, do NOT use this form. You must use CGFNS or FCCPT to verify
your licensure status.
1.
Complete Section 1. Enter your name as it appears on your Application (Form 1). Be sure to sign and date item 7.
2. Send this form with any fee required to the appropriate licensing authority of the state in which you are or have been licensed to complete
Section II and return this form directly to the Office of the Professions at the address at the end of this form.
NOTE: A separate Form 3 must be received by the Department from every state in which you are or have been licensed.
SECTION I: APPLICANT INFORMATION
1
2
SOCIAL SECURITY NUMBER
BIRTH DATE
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
PRINT FULL NAME
Last
First
Middle
MAILING
4
Street
ADDRESS
City
State
Zip Code
Province/Country
If not U.S.
5
If you took a licensing examination in the United States using a different name, enter that name below:
Last ___________________________________________ First _____________________________________ Middle ______________________
6
If licensed by examination in the United States, indicate state or territory: ___________________________________________________________
Date license was issued: ________ / ________ / ________ License number: ________________________________________________________
I request and give my permission to the licensing authority listed in item 6 above to complete the information on this form and mail it to the New York
7
State Education Department and to release any other information required by the State Education Department in connection with my application for
licensure.
Applicant's signature: _______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
CERTIFICATION OF LICENSURE IS TO BE MADE BY LICENSING AUTHORITY ON NEXT PAGE
February 2003
FORM 3, PAGE 1 OF 2
SECTION II : CERTIFICATION OF LICENSURE
INSTRUCTIONS TO LICENSING AUTHORITY:
Please complete this section and return this form directly to the Office of the Professions at the address
at the end of this form. This form will not be accepted if returned by the applicant. Attach additional sheets if necessary.
1. Name of applicant
: ________________________________________________________________________________________________
2. Profession in which applicant is licensed in your jurisdiction:
Physical Therapy
Physical Therapist Assistant
3.
L icense number: ___________________________________________ Date of licensure: ________ / ________ / ________
Mo.
Day
Yr.
4. Jurisdiction issuing original license or certification: ____________________________________________________________
5. Is the individual currently licensed or registered?
Yes
No If Yes, Date of expiration:
________ / ________ / ________
Mo.
Day
Yr.
6. Please indicate if the license was issued under any of the following special conditions (check all that apply):
Endorsement of licensure in another jurisdiction (please identify: ______________________________________)
Waiver of examination
Waiver of education
Other (please attach explanation)
7. If the license was issued based on an examination, please indicate the examination title, date and score (eg. National Physical
Therapy Examination; PES/ASI Examination; State Examination, etc.):
Examination title _____________________________________________
Date _____ / _____ / _____ Score ________________
8.
Did the issuance of this license involve any practice limitations?
Yes
No
9.
Was there ever any disciplinary action against this license?
Yes
No
(If the answer to question 5 or 6 is yes, please describe in detail and attach.)
10. Are there any disciplinary charges pending against this license or has he/she surrendered a license to
Yes
No
avoid disciplinary charges?
CERTIFICATION
I certify that to the best of my knowledge and belief the foregoing is a true statement of the record of the applicant named on this
form. I further certify that, other than those listed above or attached, this licensing authority has never taken any disciplinary action
against this person and that, in so far as the licensing authority has knowledge, there have been no charges preferred nor has any
information been presented relating to any question of unprofessional or immoral conduct .
Signature __________________________________________________________________________ Date _______ / _______ / _______
Title _______________________________________________________________________
Agency _____________________________________________________________________
Address ____________________________________________________________________
(LICENSING AUTHORITY
____________________________________________________________________________
SEAL)
Telephone number ____________________________ Fax ___________________________
E-mail _____________________________________________________________________
RETURN DIRECTLY
New York State Education Department, Office of the Professions, Division of Professional Licensing Services, Physical
Therapy Unit, 89 Washington Avenue, Albany, New York 12234-1000
TO
February 2003
FORM 3, PAGE 2 OF 2
Page of 2