Management Branch Office of Licensing

VERIFICATION OF PHYSICAL THERAPY PRACTICE Applicant: If you are seeking certification/licensure by endorsement based on practice as a physical therapist or physical therapist assistant for two of the last five years, request your employer(s) to complete this form. Submit the completed form(s) with your application.

This is to certify that Applicant Last Name

First Name

was actively practicing physical therapy from

Middle Name

to mm/dd/yy

Suffix

for mm/dd/yy

hours per week. Employer Signature:

Signature Date:

Employer Name:

Employer Title/Position:

(print)

Employer Business Name: Employer Business Address:

Street and Number: City, State, Zip:

Employer Telephone Number: ( )

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

F 303.894.7693 www.dora.colorado.gov/professions