Physical Therapy Form 4A "Certification of Professional Experience for Endorsement Applicants" - New York

What Is Physical Therapy Form 4A?

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 4A 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 4A "Certification of Professional Experience for Endorsement Applicants" - New York

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The University of the State of New York
Physical Therapy
Assigned No.
THE STATE EDUCATION DEPARTMENT
(From Form 4)
Office of the Professions
Form 4A
Division of Professional Licensing Services
__________
www.op.nysed.gov
Certification of Professional Experience for
Endorsement Applicants
This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy
issued in another jurisdiction.
Applicant Instructions
1. Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 7.
2. Send this entire form to your colleague to complete Section II. The colleague must return both pages of the form directly to the Office of
the Professions at the address at the end of the form. If additional copies are needed, you may photocopy this form. This form will not
be accepted if returned by the applicant.
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 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
Name at time of employment (if different from above): _________________________________________________________________
6
Name of colleague: ____________________________________________________________ Assigned number from Form 4 _______
I practiced licensed physical therapy as defined below:
“The Practice of physical therapy is defined as the evaluation, treatment or prevention of disability, injury, disease, or other condition of
health using physical, chemical, and mechanical means including, but not limited to heat, cold, light, air, water, sound, electricity,
massage, mobilization, and therapeutic exercise with or without assistive devices, and the performance and interpretation of tests and
measurements to assess pathophysiological, pathomechanical, and developmental deficits of human systems to determine treatment,
and assist in diagnosis and prognosis.”
Jurisdiction where I practiced physical therapy: _______________________________________________________________________
Date of licensure: _______ / ______ / _______ License number ____________________
mo.
day
yr.
7
I request and give my permission to the individual listed in item 6 to complete Section II of this form and mail it to the New York State
Education Department at the address at the end of this form, and to release any other information requested by the State Education
Department in connection with my application for licensure. I also declare and affirm under penalty of perjury that the statements made
in this application, including accompanying documents, 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 or loss of licensure and may result in criminal prosecution.
_____________________________________________________________________________ Date ________ / _______ / ________
Signature of applicant
mo.
day
yr.
Physical Therapy Form 4A, Page 1 of 2, December 2012
1.
2.
3.
.
.
The University of the State of New York
Physical Therapy
Assigned No.
THE STATE EDUCATION DEPARTMENT
(From Form 4)
Office of the Professions
Form 4A
Division of Professional Licensing Services
__________
www.op.nysed.gov
Certification of Professional Experience for
Endorsement Applicants
This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy
issued in another jurisdiction.
Applicant Instructions
1. Complete Section I. In item 3, enter your name as it appears on your Application for Licensure (Form 1). Be sure to sign and date item 7.
2. Send this entire form to your colleague to complete Section II. The colleague must return both pages of the form directly to the Office of
the Professions at the address at the end of the form. If additional copies are needed, you may photocopy this form. This form will not
be accepted if returned by the applicant.
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 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
Name at time of employment (if different from above): _________________________________________________________________
6
Name of colleague: ____________________________________________________________ Assigned number from Form 4 _______
I practiced licensed physical therapy as defined below:
“The Practice of physical therapy is defined as the evaluation, treatment or prevention of disability, injury, disease, or other condition of
health using physical, chemical, and mechanical means including, but not limited to heat, cold, light, air, water, sound, electricity,
massage, mobilization, and therapeutic exercise with or without assistive devices, and the performance and interpretation of tests and
measurements to assess pathophysiological, pathomechanical, and developmental deficits of human systems to determine treatment,
and assist in diagnosis and prognosis.”
Jurisdiction where I practiced physical therapy: _______________________________________________________________________
Date of licensure: _______ / ______ / _______ License number ____________________
mo.
day
yr.
7
I request and give my permission to the individual listed in item 6 to complete Section II of this form and mail it to the New York State
Education Department at the address at the end of this form, and to release any other information requested by the State Education
Department in connection with my application for licensure. I also declare and affirm under penalty of perjury that the statements made
in this application, including accompanying documents, 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 or loss of licensure and may result in criminal prosecution.
_____________________________________________________________________________ Date ________ / _______ / ________
Signature of applicant
mo.
day
yr.
Physical Therapy Form 4A, Page 1 of 2, December 2012
Section II: Certification of Experience
Instructions to Colleague: Complete Section II, Items A and B, sign and date the attestation and send both pages of this form directly to
the address at the end of this form. This form will not be accepted if returned by the applicant.
A. Colleague’s Qualifications:
I am a licensed _______________________________________________________________ in ______________________________
Professional Title
Jurisdiction
________________________________________________________________________ ___________________________________
License number (Attach a copy of your license if other than New York)
Date licensed
B. Experience Information: I am attesting that ________________________________________________________________________
Applicant Name
practiced physical therapy (defined in Section I, item 6) as follows.
_____________________________________________________________________________________________________________
Address of setting where experience took place
City
State
Zip Code
F Present
Dates of licensed Experience:
From _______ / _______ / _______ To _______ / _______ / _______
mo.
day
yr.
mo.
day
yr.
Affirmation (To be completed by colleague verifying experience)
I declare and affirm under penalty of perjury that the statements made in the foregoing application, including any attached statements,
are true, complete and correct and that the experience I am attesting to meets the definition of licensed practice in physical therapy.
F Check here if you are attaching additional information.
Signature: ______________________________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print Name: _____________________________________________________________________
Address:________________________________________________________________________
________________________________________________________________________
Phone: _________________________________ Fax: ___________________________________
E-mail: _________________________________________________________________________
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 4A, Page 2 of 2, December 2012
Page of 2