Forms

APPLICANT FORMS

• Applicants Name/Address Change Form
• Application for Licensure
• Certificate of Completion (P1E)
• Verification of Clinical Experience for a PTA Equivalency Applicant
• Request for Special Accommodations (D1) & Instruction for Evaluators
• Fingerprint Information & Live Scan Form
• Approved Credential Evaluation Services
• Notice of Intent to Supervise a Foreign Educated Physical Therapist (NOI) Form
• Clinical Site Instructions Form (CSIF) for Foreign Educated Physical Therapist Applicant - available on the APTA's website
• Work Verification Form for a Foreign Educated Applicant - Period of Clinical Service (Only for those applicants that are already licensed in another State in the U.S.)
• Sponsored Free Health Care - Sponsoring Entity Registration Form
• Request for Authorization to Practice Without a California License at a Sponsored Free Health Care Event

LICENSEE FORMS

• Application for Endorsement/Verification Letter
• Licensee Name/Address Change Form
• Request Duplicate Wall or Wallet License Form
• License Renewal - Criminal Conviction Disclosure Requirements
• Criminal Conviction Questionnaire
• Statement of Renewal

CONTINUING COMPETENCY

• Continuing Competency Disclosure Questionnaire
• Inactive to Active License Status Application
• Continuing Competency Activities and Coursework Checklist
• Continuing Competency Exemption Application

CONSUMER PROTECTION FORMS

• Consumer Complaint Form
• Authorization of Patient Health Information
• For additional information on How to File a Complaint, please click here.
• How to Become an Expert Consultant/Practice Monitor for the Board
• Expert Consultant/Practice Monitor Selection Criteria
• Expert Consultant/Practice Monitor Application

PETITION FOR PENALTY RELIEF REINSTATEMENT OF LICENSE/MODIFICATION AND⁄OR TERMINATION OF PROBATION

• Instructions for Preparing Petition Application
• Business & Professions Code 2661.7 Petition for Modification
• Petition for Reduction of Penalty Application