Physical Therapist Assistant License Renewal Form

Physical Therapist Assistant License Renewal Form
Renew your PTA license by providing the required information below. Please ensure all details are accurate and up to date.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Last 4 Digits of License Number
Current Employment Status
Other
Have you completed the required continuing education (CEU) hours for this renewal period?
Have you been convicted of any criminal offense or had disciplinary actions taken against your license since your last renewal?
If you answered 'Yes' above, please provide a brief explanation. If not, type 'N/A'.
Should be Empty: