Management Branch Office of Licensing

CERTIFICATION OF PHYSICAL THERAPIST EDUCATION To be completed by applicant and forwarded to school where degree will be awarded. Please complete and return this form, along with an unofficial copy of the applicant’s transcripts, to the Division of Professions and Occupations. SECTION 1 – To be completed by Applicant This certifies that __________________________________________________________________________ is Full Name of Applicant

enrolled in _______________________________________________________________________________ in Full Name of School and Program

___________________________________________ since the __________ day of _______________, _________. Location of School

Day

Month

Year

SECTION 2 – To be completed by School President, Dean or Registrar This undersigned certifies that the applicant listed above has successfully completed the Physical Therapy program and that the applicant has or will be granted a degree on the __________ day of Day

_____________________, __________. Month

Year

Signed This ___________ day of ________________________________________, ____________________. Day

Month

Year

By___________________________________________________________________________________________ President / Dean / Registrar

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions

Certification of Physical Therapy Education.pdf

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