Expert Consultant Practice Monitor Application - the Physical 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the designated field, ensuring you include your last name, first name, and middle initial.
3. Fill out your residence address and mailing address if it differs from your residence. Include street address, city, state, and zip code.
4. Provide your home, cellular, and work telephone numbers along with your email address for contact purposes.
5. Enter your PT license number and place of employment details including expiration date of the license.
6. Respond to the questions regarding your practice involvement and any disciplinary actions by selecting 'Yes' or 'No' as applicable. Attach explanations on a separate sheet if necessary.
7. List any continuing education courses completed in the past three years and indicate any instructional roles held in educational programs over the past five years.
8. Identify counties you are willing to travel to as an expert consultant/practice monitor.
9. Review all entered information for accuracy before signing at the bottom of the application.

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