Endorsement
Exam
PT
PTA
Applying for Licensure
Check One of Each
North Carolina Board of Physical Therapy Examiners
Character Reference
To be Completed by Applicant
City:
State:
Zip Code:
Address:
Name:
Maiden Name:
To be completed by a person who has known the applicant for at least 1 year and is not a relative.
Do NOT give this reference document back to the applicant.
Please Do NOT put their address or name in the return address section of the your envelope.
This certifies that I have been acquainted with the named applicant and can attest to their *good moral character.
name of applicant
from
(month / year) to
(month / year) or
Reference must be mailed to the address below, directly by person signing this form.
North Carolina Board of Physical Therapy Examiners
8300 Health Park, Suite 233
Raleigh, NC 27615
Phone: 919-490-6393
or 800-800-8982
Signature (no electronic signatures)
Address
Date
City State
Zip Code
Foreign Trained
US Trained
Title
Last
First
Middle
Email:
Name (must be legible)
the present.
*Good moral character means a “personal history of honesty, fairness, and respect for the rights of others and the laws of the state and nation.”
If there is any additional information concerning the good moral character or technical fitness of the applicant that you feel the Board should
know, please attach a written explanation.
Individual attesting to the character reference above.
in the following capacity:
