ONLINE EXAM REGISTRATION

Section 1--Candidate Information

fields marked with a "*" are required
*Name:
* Email:
*NAIOMT ID #**	**first & last initials followed by the last 4 digits of your SSN
*Address 1			Address 2
*City	*State		*Postal Code
Country (if other than US)
*Phone	Home Work Cell
Phone 2	Home Work Cell
Fax
*PT License #		*State	*Exp. Date
By Submitting this exam application I am certifying that I am a licensed physical therapist

Section 2--Exam Information (choose all that apply)
Level I - 500	Level II UQ - 600	Level II LQ - 610
September 18, 2008 November 15, 2008 January 17, 2009 March 12, 2009 May 16, 2009 September 10, 2009 November 14, 2009	September 18, 2008 November 15, 2008 January 17, 2009 March 12, 2009 May 16, 2009 September 10, 2009 November 14, 2009	September 18, 2008 November 15, 2008 January 17, 2009 March 12, 2009 May 16, 2009 September 10, 2009 November 14, 2009

Section 3--Proctor Information (email address and phone number must be different from candidate)
*Name:	* Relationship:
*Phone		Fax
*Email
To take the online examinations your proctor must have an individual email address separate from the candidate/s.  Both the candidate and their proctor are responsible for checking their email on a regular basis prior to the examination date as all communications from the examination coordinator will be via email.  Candidates and proctors will be emailed confidential instructions sometime during the week prior to the examination date.  NAIOMT now has a study guide with sample examination questions. Click here to download This detailed study guide will assist you in preparing for the exam/s.
After submitting this form, you will be directed to NAIOMT's secure online payment page.