Physical Therapist Assistant Application Instructions ...

1 New Jersey Office of the Attorney GeneralDivision of Consumer AffairsState Board of Physical Therapy Examiners124 Halsey Street, 6th Floor, Box 45014 Newark, New Jersey 07101(973) 504-6455 Physical Therapist AssistantApplication Instructions / ChecklistUse this checklist to determine whether you have complied with all of the requirements for licensure in New Jersey as a Physi-cal Therapist Assistant . Once your Application has been received, a file will be established and you will be notified regarding any missing approval of your Application , you will be notified by letter and requested to provide your initial license note that as of February 17, 2003, the State Board of Physical Therapy Examiners is no longer issuing temporary licenses. Application Fee: Please enclose a nonrefundable check or money order in the amount of $ to the State Board of Physical Therapy Examiners and mail it with your Application to: State Board of Physical Therapy Examiners, Box 45014, Newark, 07101.

2 There are two ways to obtain a license in New Jersey:1. Apply to take the National Physical Therapist Assistant Exam ( ).2. Apply by endorsement. The applicant must meet all of New Jersey s requirements even if he or she is licensed in another state or jurisdiction. Answer all of the questions on the Application form. Attach one passport-style photograph of your head and shoulders to the front page of the Application . Please sign and print your name along with the date on the back of the photo. Enter your Social Security number. (If you do not have a Social Security number at the time that you apply, you must obtain one prior to being issued a permanent license number. In addition, you must provide a photocopy of your Social Security card with your signature on the photocopy. Please remember to write the Social Security number below your signature on the photocopy.)

3 All applicants who have had a name change since Physical Therapist Assistant school due to naturalization, marriage, divorce or other decrees, must submit legal documentation. Have your school(s) provide an official transcript in a sealed envelope. Do not open the envelope. Attach each sealed transcript to the Application , or arrange to have the school(s) forward the transcript(s) directly to the Board office. Make photocopies of the Verification of State License form and mail it to each state in which you hold (or have held) a license. The board in each state where you are or have been licensed must fill out the form, stamp it with the board s official seal and mail it directly to: State Board of Physical Therapy Examiners, Box 45014, Newark, New Jersey 07101. Please contact each state office for the necessary processing fees for verification before mailing out your verification forms.

4 If you are seeking endorsement, you must submit a photocopy of your current license/registration that shows the expiration date. If you have previously taken the , please have your official scores sent directly to the Board office at: State Board of Physical Therapy Examiners, Box 45014, Newark, New Jersey 07101. You may reach the Federation of State Boards of Physical Therapy Examination Service at (703) use additional paper if you cannot fit all of your information in the space provided on this form. Make a notation by each question that more information has been attached. Please mark your attached answers with the same number corresponding to the question that you are answering. If you have any disabilities that require any accommodations at the testing site for the , please complete the Documentation of Disability Related Needs form.

5 If you answered Yes to any of the child-support questions, please attach to this Application an explanation written on a separate sheet of paper. All applicants must take and pass the Jurisprudence Assessment Module for New Jersey which can be found on the Federation of State Boards of Physical Therapy s website at Fill out the medical conditions section on this Application . Fill out the Certification and Authorization form for a criminal history record background check and mail it with the Application to the Board. Once the entire Application has been completed, have it signed and stamped/sealed by a notary applicant filing an Application after November 22, 2003, will be subject to a criminal history record background check pursuant to 2002, Chapter 104. Information regarding this background check will be provided to Jersey Office of the Attorney GeneralDivision of Consumer AffairsState Board of Physical Therapy Examiners124 Halsey Street, 6th Floor, Box 45014 Newark, New Jersey 07101(973) 504-6455 Application for Licensure as a Physical Therapist Assistant Date: _____ A nonrefundable Application filing fee of $125, in the form of a check or money order made out to the State of New Jersey, must be submitted with this Application .

6 (Applicants should understand that if the Application filing fee is paid with a personal check, and the check is returned by the bank due to insufficient funds, the next step in the licensure or certification process will be delayed until the fee is paid.)The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their consent. However, you are required to provide an address that may be released to the public in our directories or in response to other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of your place of residence, you should provide an address of record other than your place of residence that may be released to the public.

7 One of your addresses must include a street, city, state and ZIP code. Information that you provide on this Application may be subject to public disclosure as required by the Open Public Records Act (OPRA).Please print clearly. You must answer all of the questions on this Information Date of birth: _____ Month Day Year Name Mrs. _____( _____) Ms. Last name First name Middle initial Maiden name2. Address Home: _____ Street or Box City State ZIP code County _____ _____ Telephone number (include area code) E-mail address Business: _____ Name of company Telephone number (include area code) _____ Street City State ZIP code County Mailing: _____ Street or Box City State ZIP code CountyAttach a clear, full-face passport-style photograph (2 x 2 ) of your head and shoulders, taken within the past six months.

8 A photo is required with each not use staples to attach the Social Security Number You must disclose your Social Security number for the reasons stated below. Failure to do so may result in a denial of licensure or certification or license or certificate renewal. *Social Security Number: _____- _____- _____*Pursuant to 54:50-24 et seq. of the New Jersey taxation law, 2 of the New Jersey Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 , and , the Board is required to obtain your Social Security number. Pursuant to these authorities, the Board is also obligated to provide your Social Security number to:a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing compliance with State tax law and updating and correcting tax records;b.

9 The Probation Division or any other agency responsible for child support enforcement, upon request; andc. the National Practitioner Data Bank and the Data Bank, when reporting adverse actions relating to health care Citizenship / Immigration StatusFederal law limits the issuance or renewal of professional or occupational licenses or certificates to citizens or qualified aliens. To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not a citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the office of Citizenship and Immigration Services (USCIS). citizen Alien lawfully admitted for permanent residence in Other immigration statusQuestions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the USCIS at: Student Loan Are you in default in regard to any student loan obligation(s)?

10 Yes No If Yes, you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certificate unless you provide the required documents concerning the plan for repayment of your student Child Support Please certify, under penalty of perjury, the following: a. Do you currently have a child-support obligation? Yes No (1) If Yes, are you in arrears in payment of said obligation? Yes No (2) If Yes, does the arrearage match or exceed the total amount payable for the past six months? Yes No b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding?