Physical Therapy Form 1 "Application for Licensure" - New York

What Is Physical Therapy Form 1?

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 November 1, 2018;
  • 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 fillable version of Physical Therapy Form 1 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 1 "Application for Licensure" - New York

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This Area For Department Use Only
The University of the State of New York
Physical Therapy
The State Education Department
Office of the Professions
Form 1
Division of Professional Licensing Services
Application for Licensure
www.op.nysed.gov
All applicants for licensure must complete this form and submit it with the
appropriate fee
directly to the
Office of the Professions at the address at the end of this form. You must answer all questions in ink (pen or
printer) and provide all information requested unless otherwise indicated. Failure to complete all required parts
of the application will delay its review. You must sign and date the Affidavit on this form in the presence of
a Notary Public.
Check what you are applying for (check one):
62 $294 ER
66
$103
ER
Physical Therapist (License)
Physical Therapist Assistant (License)
62 $70 PR
66 $50 PR
Physical Therapist (Permit)
Physical Therapist Assistant (Permit)
1.
2.
Birth Date
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
Last
3.
Print Name
5. Telephone/Email Address
First
Daytime Phone
Middle
Home or
Business
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Area Code
Prefix
Line Number
4.
Mailing Address
Home or
Business
Email Address (please print clearly)
(You must notify the Department promptly of any address or name changes)
Home or
Business
Line 1
Line 2
Line 3
6. New York State DMV ID Number
(Driver or Non-Driver ID)
City
State
ZIP Code
(Leave this blank if you do not have a
New York State DMV ID Number)
Country/
Province
7.
Name as it appears on degree or other credentials (if different from above)
8.
Have you previously applied for New York State licensure in any profession?
Yes
No
If "yes", in what profession(s)?
9.
Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime
Yes
No
(felony or misdemeanor) in any court?
10. Are criminal charges pending against you in any court?
Yes
No
11. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,
Yes
No
accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate
held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you?
12. Are charges pending against you in any jurisdiction for any sort of professional misconduct?
Yes
No
13. Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training,
Yes
No
employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association
to avoid imposition of such measures?
NOTE: If you answer "Yes" to any questions numbered 9-13, submit a letter giving a complete detailed explanation. Include copies of any court
records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can
no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your
application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed.
Physical Therapy Form 1, Page 1 of 4, Revised 11/18
This Area For Department Use Only
The University of the State of New York
Physical Therapy
The State Education Department
Office of the Professions
Form 1
Division of Professional Licensing Services
Application for Licensure
www.op.nysed.gov
All applicants for licensure must complete this form and submit it with the
appropriate fee
directly to the
Office of the Professions at the address at the end of this form. You must answer all questions in ink (pen or
printer) and provide all information requested unless otherwise indicated. Failure to complete all required parts
of the application will delay its review. You must sign and date the Affidavit on this form in the presence of
a Notary Public.
Check what you are applying for (check one):
62 $294 ER
66
$103
ER
Physical Therapist (License)
Physical Therapist Assistant (License)
62 $70 PR
66 $50 PR
Physical Therapist (Permit)
Physical Therapist Assistant (Permit)
1.
2.
Birth Date
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
Last
3.
Print Name
5. Telephone/Email Address
First
Daytime Phone
Middle
Home or
Business
Licensee business address, phone and email address are public information. Failure to
indicate business or home on this form for each item will deem it public information.
Area Code
Prefix
Line Number
4.
Mailing Address
Home or
Business
Email Address (please print clearly)
(You must notify the Department promptly of any address or name changes)
Home or
Business
Line 1
Line 2
Line 3
6. New York State DMV ID Number
(Driver or Non-Driver ID)
City
State
ZIP Code
(Leave this blank if you do not have a
New York State DMV ID Number)
Country/
Province
7.
Name as it appears on degree or other credentials (if different from above)
8.
Have you previously applied for New York State licensure in any profession?
Yes
No
If "yes", in what profession(s)?
9.
Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime
Yes
No
(felony or misdemeanor) in any court?
10. Are criminal charges pending against you in any court?
Yes
No
11. Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled,
Yes
No
accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate
held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you?
12. Are charges pending against you in any jurisdiction for any sort of professional misconduct?
Yes
No
13. Has any hospital, licensed facility or clinical laboratory restricted or terminated your professional training,
Yes
No
employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association
to avoid imposition of such measures?
NOTE: If you answer "Yes" to any questions numbered 9-13, submit a letter giving a complete detailed explanation. Include copies of any court
records including a Certificate of Disposition. If there are offenses in multiple courts, please provide the same for each action. If the court can
no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. While your
application is pending, you must notify the Division of Professional Licensing Services if the answers to any of these questions have changed.
Physical Therapy Form 1, Page 1 of 4, Revised 11/18
14. Do you now hold, or have you ever held, a license or certificate to practice any profession in any jurisdiction?
Yes
No
If yes, you must list all licenses/certificates, states or jurisdictions and provide appropriate information in the columns below or
your application will be delayed. A Form 3 must be submitted for each professional license/certificate listed unless it is a
license/certificate issued by the New York State Education Department. See the Applicant instructions on Form 3 for specific
information about completing and submitting the form.
Date License/Certificate
License/Certificate
Limitations
Professional Title
State or Jurisdiction
Issued
Number
on License/Certificate
15. You must complete all information for all schools/colleges/universities attended or your application will be considered
incomplete.
High School/Secondary School or Equivalency Diploma Issuer - Please complete the section below with details about your high
school/secondary school or equivalency diploma issuer. Attach additional sheets if you attended multiple schools. Any missing information
will be considered an incomplete application.
Name of School
City
Country
State/Province
to
Attendance from
Completion date
Number of years attended
mo.
yr.
mo.
yr.
mo.
yr.
Postsecondary Education - Please complete the section below with details about your postsecondary education. Use spaces below as
needed and attach additional sheets if necessary. Any missing information will be considered an incomplete application.
a.
Name of School
City
State/Province
Country
Major/Concentration
to
Attendance from
Number of years attended
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in original language)
Or
Still in progress
Date Degree/Diploma/Certificate awarded
mo.
yr.
b.
Name of School
City
State/Province
Country
Major/Concentration
to
Attendance from
Number of years attended
mo.
yr.
mo.
yr.
Or
Still in progress
Title of Degree/Diploma/Certificate awarded (in original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
c.
Name of School
City
State/Province
Country
Major/Concentration
to
Attendance from
Number of years attended
mo.
yr.
mo.
yr.
Or
Still in progress
Title of Degree/Diploma/Certificate awarded (in original language)
Date Degree/Diploma/Certificate awarded
mo.
yr.
Physical Therapy Form 1, Page 2 of 4, Revised 11/18
16. Reasonable Testing Accommodations for Individuals with Disabilities. (check if applicable)
I have been diagnosed as having a disability and require special testing accommodations and am submitting the Request for Reasonable Testing
Accommodations form. I understand that I will not be able to test until I submit the appropriate documentation and am approved to test with
accommodations. (Visit the
Office of the Professions' website
for information on obtaining the form.)
17. Child Support Obligation
Everyone applying for a professional license, permit, or registration, or any renewal thereof, must certify that, as of the date of the filing,
she or he is, or is not, under an obligation to pay child support*. Individuals who are four months or more in arrears in child support
or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding may be
subject to suspension of their business, professional, drivers and/or recreational licenses and permits. The intentional submission
of false written statements for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under
section 175.35 of the Penal Law.
You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with
their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child support
obligations.
CHECK ONLY A OR B BELOW. If you check B, you must check one of the five statements listed below it.
A
I am not under an obligation to pay child support;
Or
B
I am under an obligation to pay child support and (please check only one of the following)
I am current and am not four months or more in arrears in the payment of child support; or,
I am making payments by income execution or by court agreed payment plan or by a plan agreed to by the parties; or,
The child support obligation is the subject of a pending court proceeding; or,
I am receiving public assistance or supplemental security income; or,
None of the above four statements apply.
*New York State General Obligations Law, section 3-503
18. Citizenship/Immigration Status
Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses,
registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation,
you must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
I am:
A United States citizen or National.
A.
B.
An alien lawfully admitted for permanent residence in the United States.
C.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1
E.
year.
F.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April
G.
1980.
Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach
H.
a copy of your passport if you are not required to have a Visa to enter the United States.
I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or
similar relief from deportation. Please specify
J.
I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship
and Immigration Services (USCIS):
USCIS number
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL
LAW SHOULD BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283,
OR VISIT THE
USCIS WEBSITE
(www.uscis.gov).
Physical Therapy Form 1, Page 3 of 4, Revised 11/18
19. Gender and Ethnicity (This item is optional)
Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and analyze data
concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and
program evaluation purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for
licensure.
Gender
Male
Female
Ethnicity
White (not Hispanic)
Black (not Hispanic)
Asian
Hispanic
Native American
20. Education Program Review
I give permission to the New York State Education Department to release my examination results to my professional school for the
confidential purposes of program review and institution research and planning. I may rescind this authority at any time by notifying the
Division of Professional Licensing Services in writing.
Yes
No
Please initial
21. Affidavit with Acknowledgement (Notarization required)
Applicant
I declare and affirm 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. This form must be signed and dated in the presence of a Notary Public.
Applicant's Signature
Date
Notary
State of
County of
On the
day of
in the year
before me, the above signed,
personally appeared
, personally known to me or proved to me on the basis
Applicant name
of satisfactory evidence to be the individual whose name is subscribed to this application and acknowledged to me that he/she executed
the application and swore that the statements made by him/her in the application and all supporting materials are true, complete, and
correct.
Notary Public's Signature
Notary Stamp
Notary ID number
Expiration Date
If you are submitting an initial Form 1; mail this form and appropriate fee to: New York State Education Department, Office of the
Professions, PO Box 22063, Albany, NY 12201, U.S.A.. DO NOT SEND CASH. Make check or money order payable to the New York State
Education Department.
If the Department has requested an updated Form 1; mail this form to: New York State Department, Office of the Professions, Physical
Therapy Unit, 89 Washington Avenue, Albany, NY 12234-1000. U.S.A.. NO FEE IS NEEDED FOR THIS OPTION.
Physical Therapy Form 1, Page 4 of 4, Revised 11/18
Page of 4