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Form 4 - Endorsement Applicant Professional Experience Record

This form is for applicants seeking licensure in New York State by endorsement of a license to practice physical therapy issued in another jurisdiction.

Complete and send both pages of this form directly to the Office of the Professions at the address at the end of the form. Be sure to sign and date item 8.

You must also complete a separate Form 4A for each colleague you list on the Endorsement Applicant Professional Experience Record (Form 4).