Forms

APPLICANT FORMS

• Applying by Exam (18-076)
• Applying by Endorsement (18-199)
• Request for Address Change
• Request for Name Change
• Application for Examination and/or Licensure
• Certificate of Completion (P1E)
• Fingerprint Information and Live Scan Form
• Request for Special Accommodations (D1) & Instructions for Evaluators
• Verification of Clinical Experience for a PTA Equivalency Applicant
• Approved Credential Evaluation Services
• Notice of Intent to Supervise a Foreign Educated Physical Therapist (NOI) Form
• 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.)

LICENSEE FORMS

• Request for Address Change
• Request for Name Change
• Request for Endorsement
• Request for Duplicate Certificate
• Request for Retired License Status
• License Renewal - Criminal Conviction Disclosure Requirements
• Criminal Conviction Questionnaire
• Statement of Renewal
• Form NTC 12-01, August 2, 2012 – Notice to Consumers
• Spanish Translation
• Tagalog Translation
• Hindi Translation
• Russian Translation
• Simplified Chinese Translation

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