NORTH CAROLINA BOARD OF PHYSICAL THERAPY EXAMINERS
Certification of Education for Physical Therapy
To be completed by applicant
Name:
Maiden Name:
Address 1:
City:
State:
Zip code:
Class of:
To be completed by the school:
MM/DD/YYY
Official Name of School
School Street Address
City
State
Zip Code
S E A L
________________________________________
Signature of authorized representative of school
Print name and title
(APPLICANT MUST NOT COMPLETE ANY OF THE SECTONS BELOW)
on
type of degree received
conferred on
Date
MM/DD/YYY
I hereby certify that the individual named above has
successfully completed the didactic and clinical education
requirements of the physical therapy program at the
school named and location below.
Graduate:
(impress or electronic Seal of institution over signature)
Email address on file with NCBPTE:
If school does not have a seal, form must be notarized.
I , _____________________________________________ do hereby state that this institution does not have an official seal and that the statements on this form are true in
every respect. Signed:_______________________________________________________ Sworn to before me this ______________ day of __________________, 20____.
Signature of Notary Public (affix seal):___________________________________________ my commission expires: _______________.
Do not send this form back to applicant.Form must be returned directly by the school either by:
email - PTBoard@ncptboard.org
mail - to North Carolina Board of Physical Therapy Examiners, 8300 Health Park, Suite 233, Raleigh, North Carolina 27615.
Please note that the NCBPTE will accept electronic Certification of Education forms only if they are sealed by your school with (1) an
embossed seal which has been darkened and is legible; or (2) a stamped seal which is legible; or (3) an electronic image seal. If you
have questions please email PTBoard@ncptboard.org. Pre-dated forms will not be accepted.
