Physical Therapist Assistant: Temporary Permit

Public Health: Physical Therapist Assistant: Temporary Permit

DPH Data Management and Governance (PLIS)
INSTRUCTIONS TO THE APPLICANT:
1. Have the supervising physical therapist complete Part II of this form.
2. Return the form to the Physical Therapist Assistant Licensure, 410 Capitol Ave., MS# 12 APP, P.O. Box 340308, Hartford, CT 06134.
3. Upon receipt of this form by the Department, the applicant will be mailed an official temporary permit.
4. If you should change employers, a new permit will be required.
PART 1: TO BE COMPLETED BY THE APPLCIANT
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number:
Date of Birth:

MonthDayYear
Signature of Applicant:
Please enter full legal name
Date:

MonthDayYear
PART II: TO BE COMPLETED BY THE SUPERVISING PHYSICAL THERAPIST
Name:

First NameLast Name
Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
License Number
I certify that I am employed in the facility where the temporary permittee will be employed. I understand that direct supervision requires my immediate physical presence at all times that the temporary permittee engages in physical therapy services
Signature of Supervising Physical Therapist:
Date:

MonthDayYear
Should be Empty:

Public Health: Physical Therapist Assistant: Temporary Permit