Score Transfer Request Application Form - 2000
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1The FSBPT Score Transfer Service
For Office Use Only
National Physical Therapy Examination (PT/PTA)
DA
Score Transfer Request Application
RN
Effective 7/1/99
FEE
Note: Omissions or errors will result in delays. Please follow the instructions.
1. Applicant Information
Current Last Name:
First:
MI:
Name at time of Exam (last, first, middle, if different):
Other Names:
Current Address:
(street, apt.)
(city, state/province)
(zip code)
E-mail Address:
Telephone Number (work):
(home):
Social Security Number:
School Where Physical Therapy Degree Obtained:
Mo. and Yr. Graduated:
2. Exam Information:
You must check the level (PT/PTA) of the National Physical Therapy Examination and provide the
appropriate information about the exam for which you want your score transferred.
Physical Therapist
Date Exam Taken
State Applied for Examination
Candidate ID Number
Physical Therapist Assistant
Date Exam Taken
State Applied for Examination
Candidate ID Number
3. Fees:
(a) Transfer Fee: $60.00 per examination for first transfer. $35.00 for each subsequent transfer. In the space
provided below, print the state(s) to which you want your exam score transferred.
$60.00 (first-time transfer fee for each examination)
$35.00 (each additional or subsequent transfer)
$35.00
$35.00
Total (a)
(b) Individual Score Report @ $35.00 per exam
(check box)
Total (b)
(c) Expedite Fee: Additional $10.00 for each State. Print below each State to which you are requesting expedited
transfer.
Note: The expedite fee can be avoided by applying via the web site: https://
$10.00 (first State)
$10.00 (second State)
$10.00 (third State)
$10.00 (fourth State)
Total (c)
Grand Total
4. Method of Payment:
Credit cards (MasterCard/VISA only) cashier’s check, money order, certified check, or corporate
business checks. PERSONAL CHECKS WILL NOT BE ACCEPTED.
For credit card payment, you must provide the following:Credit card type:
VISA
MasterCard
Expiration Date:
Credit Card #:
Card Holder’s Name:
I certify that the information, which I have provided above, is correct. (Your request will not be processed unless it is
signed.)
Signature:
Print Name:
Date:
Mail to: FSBPT, 509 Wythe Street, Alexandria, VA 22314
Telephone: 1-800-200-3031
08-4091i (OL 8/00)
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