Instructions for "YES" Answers to Questions (5) through (7) of the Application for License (PT-01)
A. The following documentation must be submitted with the license application. Applications for license will not be considered
without this material.
Questions 5 and 6 refer to complaints, charges of unlicensed activity, or pending disciplinary actions for any profession,
occupation, or license. If your answer is "Yes" to one or more of these questions, read paragraph "B" below, AND you must
submit the following:
i. A statement signed by you explaining the circumstances; and
ii. Copies of any documents from the agency, including final orders, petitions, complaints, findings of fact and conclusions
of law, and any other relevant documents;
2. If your application indicates a criminal conviction, read paragraph "B" below, and you must submit the following:
i. A statement signed by you explaining the circumstances leading to the conviction and detailing all activities since the
conviction, including employment and business involvements. Include job title, period of employment, employer's name,
description of duties, training attended, and educational courses attended.
ii. A copy of the court order, verdict, and terms of sentence; and
iii. If applicable, a copy of the terms of probation and/or parole and a notarized statement from your probation or parole
officer as to your compliance with the court orders;
iv. A current criminal history record check in your name from the state where the conviction occurred and the state where you
currently reside, if different. In Hawaii, you may obtain a criminal history record check from the Hawaii Criminal Justice Data
Center. Contact the Department of the Attorney General, Hawaii Criminal Justice Data Center, Kekuanao'a Building, 456 S.
King Street, Room 102, Honolulu, Hawaii 96813. Ph: (808) 587-3279 or visit their website at: ag.hawaii.gov/hcjdc. For other
states/jurisdictions, contact the local authority or Board for their forms, instructions and fees on obtaining a criminal history
All licenses, regardless of issuance date, expire on December 31 of each EVEN NUMBERED year. The licensee is
held responsible to keep his/her license current. If you let your license lapse for longer than one year, you must file
a new application and meet requirements that are in effect at the time of filing.
B. If you answered "Yes" to any of the questions (5) through (7), your application may be reviewed at a Physical Therapy Board meeting
if you have provided all applicable information and documents as described above. The Board will not review incomplete
applications. If you wish to present oral testimony at the meeting, submit a written request with your application.
LAWS & RULES The licensee is held accountable for knowing and complying with the Hawaii laws and rules of physical therapy
practice as failure to comply may result in disciplinary action. Obtain copies of the physical therapy laws, Chapter 461,
Hawaii Revised Statutes and rules, Chapter 110, Hawaii Administrative Rules by sending a written request to the
Board's address above. Chapter 436B, Hawaii Revised Statutes, the Professional and Vocational Licensing Act should
be read in conjunction with the above statutes.
The laws and rules are also posted on our website at: cca.hawaii.gov/pvl. Click on "Physical Therapy".
Pursuant to §16-110-10(d), Hawaii Administrative Rules, your application shall be considered abandoned and shall
be destroyed if a license is not issued within one year of the application date as a result of:
failure to complete licensure requirements, or (1)
take the required licensure examination, if required, or(2)
to submit the required documentation and evidence of qualifications.(3)
If the application is deemed abandoned, the applicant shall submit a new application form, documentation of
qualifications, and applicable fees in addition to meeting licensure requirements that are in effect at the time of
filing the new application.
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.