Filling in Data Indianapolis Data Fact Sheet Physical Therapists
Filling in Data Indianapolis Data Fact Sheet Physical Therapists
Filling in Data Indianapolis Data Fact Sheet Physical Therapists
INSTRUCTIONS: 1. The fee for this application is $100.00, payable to the Indiana Professional Licensing Agency, in accordance with 844 IAC 6-2-2.
2. If applying for a temporary permit, please include your fee of $50.00 in accordance with 844 IAC 6-2-2.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website at www.pla.IN.gov for the licensing requirements.
* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.
Receipt number
Receipt number
APPLICANT
Application number
License number
Are you the spouse of a member of the military who is assigned to a duty station in Indiana? (Optional)
Yes
No
Yes
No
Examination
Endorsement
Physical Therapist
Yes
No
Have you previously taken the licensure or certification examination for Physical Therapy or Physical Therapists Assistant? (If yes, please list date and place.)
Yes
No
Have you previously failed the licensure or certification examination in Indiana or any other state? (If "Yes", please give details as to where and when.)
Yes
No
TEMPORARY PERMIT
Yes
No
Name of school
LOCATION
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FROM
TO
(month, year) (month, year)
DEGREE
List all states, including Indiana, in which you have been licensed or certified to practice any regulated health profession.
Verification of all licenses listed must be submitted directly from the state licensing board.
STATE
TYPE OF LICENSE OR
CERTIFICATE
NUMBER
DATE ISSUED
(month, day, year)
CURRENT STATUS
If your answer is Yes to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent
revocation of the license or permit issued pursuant to this application.
1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held?
Yes
No
2. Have you ever been denied licensure, registration or certification in any state (including Indiana) or country?
Yes
No
3. Do you have any condition or impairment (including a history of alcohol or substance abuse) that currently interferes, or if left
untreated may interfere, with your ability to practice in a competent and professional manner?
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or
privileges revoked, suspended or subjected to any restrictions, probation or other type of discipline or limitations?
Yes
No
6. Have you ever been admonished, censored, reprimanded or requested to withdraw, resign or retire from any hospital
or health care facility in which you have trained, held staff membership or privileges or acted as a consultant?
Yes
No
7. Have you ever had a malpractice judgment against you or settled any malpractice action?
Yes
No
4. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a court,
(1) have you ever been arrested;
(2) have you ever entered into a prosecutorial diversion or deferment agreement regarding any offense, misdemeanor, or felony
in any state;
(3) have you ever been convicted of any offense, misdemeanor, or felony in any state;
(4) have you ever pled guilty to any offense, misdemeanor, or felony in any state; or
(5) have you ever pled nolo contendre to any offense, misdemeanor, or felony in any state?
APPLICATION AFFIRMATION
I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant
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