Physical Therapist Assistant: Out-of-state License Verification

Public Health: Physical Therapy Assistant Licensure

DPH Data Management and Governance (PLIS)
Verification Of Licensure/Registration

Applicant – Complete the top portion of this form and forward it to each state where you have been licensed as a physical therapist assistant (make copies as necessary).
Last Name:
First Name:
Middle Name:
Maiden Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Original License/Registration number (in the state to which the form is being forwarded) :
Date Issued:

MonthDayYear
Social Security Number:
I hereby authorize the Licensing agency name* to furnish the Connecticut Department of Public Health the information requested below.
Signature:
Please enter full legal name
Date:

MonthDayYear
Licensing Agency

Please complete the portion below and forward to the address indicated.
This is to certify that the above named individual was issued license/registration number
To practice as physical therapist assistant effective:

MonthDayYear
Basis for licensure in your state:
Current Status:
Expiration Date:

MonthDayYear
IMPORTANT
Has the individual ever been subjected to the disciplinary action of any type or is this individual currently the subject of a pending disciplinary action or unresolved complaint?
If yes, please forward all publicly discloseable information regarding the individual’s
status and the basis for same.
Signed:
Title:
State:
Date:

MonthDayYear
Day Time Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Please complete and return directly to: Department of Public Health
Physical Therapy Assistant Licensure
410 Capitol Avenue MS# 12APP
P.O. Box 340308
Hartford, CT 06134-0308
Fax: (860) 707-1982
Should be Empty:

Public Health: Physical Therapy Assistant Licensure

Licensing Agency

IMPORTANT