Athletic Trainer--Temporary Permit

STATE OF CONNECTICUT

DEPARTMENT OF PUBLIC HEALTH
ATHLETIC TRAINER TEMPORARY PERMIT
INSTRUCTIONS TO THE APPLICANT:

1. Have the supervising athletic trainer complete Part II of this form.
2. Return the form to the AT 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 a temporary permit.
4. If the permittee should change employers, a new permit will be required.
PART I: TO BE COMPLETED BY THE APPLICANT
Name*

First NameLast Name
Address*

Street Address

City, State, Zip

CityState / Province

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

MonthDayYear
Signature of Applicant*
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date *

MonthDayYear
PART II: TO BE COMPLETED BY THE SUPERVISING ATHLETIC TRAINER
Name

First NameLast Name
Office Address

Office Address

City, State, Zip

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
License Number
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 athletic trainer services.
Signature of Supervising Athletic Trainer
Enter Full Legal Name
I affirm or attest that this is my legal signature.
Date

MonthDayYear
Should be Empty: