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Physical Therapy Form 4a - Certification Of Professional Experience For Endorsement Applicants - New York The State Education Department Page 2

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

Dates of licensed Experience:

From _______ / _______ / _______ To _______ / _______ / _______

Present

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.

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

Physical Therapy Form 4a - Certification Of Professional Experience For Endorsement Applicants - New York The State Education Department Page 2