Filling in Data Indianapolis Data Fact Sheet Physical Therapists

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APPLICATION FOR LICENSURE AS A PHYSICAL


THERAPIST OR PHYSICAL THERAPIST'S ASSISTANT

PHYSICAL THERAPY COMMITTEE


PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204-2724
Telephone: (317) 234-8800
E-mail: pla14@pla.IN.gov
www.pla.IN.gov

State Form 9111 (R17 / 8-16)


Approved by State Board of Accounts, 2016

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.

FOR OFFICE USE ONLY


Application fee

Temporary permit fee

Date fee paid (month, day, year)

Date fee paid (month, day, year)

Receipt number

Receipt number

APPLICANT

Application number

Attach one (1) passport type quality


photographs of yourself taken
within the last eight (8) weeks.
Please sign each photo at the bottom.
Negatives and Polaroids are not acceptable.

Temporary permit number

License number

Temporary permit issuance date (month, day, year)

License issuance date (month, day, year)

DO NOT WRITE ABOVE THIS LINE


APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden)

Social Security number*

Address (number and street or rural route)


E-mail address (required)

(City, state, and ZIP code)


Telephone number (daytime)

Date of birth (month, day, year)

Place of birth (city, state or foreign country)

Are you the spouse of a member of the military who is assigned to a duty station in Indiana? (Optional)

Yes

Are you an active duty member of the military? (Optional)

No

Yes

No

BASIS FOR LICENSURE


Please check appropriate box

Examination

Endorsement

Physical Therapist

Physical Therapist's Assistant

Please check appropriate box


Have you previously filed an application for licensure/certification by examination or endorsement as a Physical Therapist or Physical Therapist's Assistant in Indiana or any other state?
(If "Yes", please give details as to where and when.)

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

Do you desire a temporary permit?

No

PHYSICAL THERAPIST / PHYSICAL THERAPIST'S ASSISTANT DEGREE GRANTED BY


Location

Name of school

Date of graduation (month, day, year)

UNDERGRADUATE AND GRADUATE TRAINING


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

PLACES OF EMPLOYMENT SINCE GRADUATION


NAME AND ADDRESS OF EMPLOYER
RESPONSIBILITIES

PLACES YOU HAVE LIVED SINCE GRADUATION


GENERAL LOCATION

DATE (month, day, year)

DATE (month, day, year)

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

Date (month, day, year)

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AUTHORIZATION FOR RELEASE OF INFORMATION


I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing
Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives
in connection with processing my application for physical therapy licensure or physical therapists assistant certification.
I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such
inspection or furnishing of any such information.
I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information
which is material to my application and I hereby specifically release the Agency and the Committee from any and all liability in connection with such
disclosures.
A photostatic copy of this authorization has the same force and effect as the original.
AFFIRMATION
I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant

Date (month, day, year)

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