Other Information

Indicate whether you have ever had any certification, registration, license, or clinical privileges revoked, suspended, or in any way restricted by an institution, state, or locality. If yes, enter an explanation in the spaces provided.

Indicate whether you have ever been dismissed or suspended from a college or university. If you answer yes, you will not automatically be disqualified from admission to a RF-PTCAS program. Full disclosure will enable programs to evaluate this information more effectively within the context of your credentials. If you fail to provide accurate information when answering this question, you may jeopardize your application.

If you select Yes, enter a brief explanation in the field provided. Include 1) a brief description of the incident, 2) specific charge made, 3) related dates, 4) consequence, and 5) a reflection on the incident and how the incident has impacted your life.

Indicate whether you have withdrawn or been dismissed from a physical therapy residency or fellowship program for any reason. If you answer yes, you will not automatically be disqualified from admission to a RF-PTCAS program. Programs understand that many individuals learn from the past and emerge stronger as a result. Full disclosure will enable programs to evaluate this information more effectively within the context of your credentials.

If you select Yes, enter a brief explanation in the field provided. Include 1) a brief description of the incident, 2) the specific charge made, and 3) a reflection on the incident and how the incident has impacted your life.