NAIOMT > CFP Info App Request

Request for Fellowship Information and Application Package


	Please read the NAIOMT Privacy Policy.

Please note:
This request is for the Fellowship Information and Application Package
and a follow-up 20 minute telephone consultation.
There is a $45 fee for this service.

The information you provide will assist us in answering your questions as you consider
applying to the NAIOMT clinical fellowship program.

Before completing this request for information:
-Please review the information on the NAIOMT web site Clinical Fellowship Program FAQ's.
-Only licensed physical therapists can apply to the NAIOMT clinical fellowship program.
-It is highly recommended that you have a minimum of 1 to 2 years of
orthopaedic clinical experience in physical therapy and have taken NAIOMT Level I and II
courses and passed the associated exams prior to beginning the fellowship.
-OCS certification is recommended by not required.
-Andrews University DSc students interested in the fellowship should apply prior to commencing their clinically supervised hours (PTH 550)

fields marked with a "*" are required

Student Info

*Name:
Different last name (eg. Maiden):
*Designations:

PT Info

*PT License #:
*PT License Exp Date:
*PT License State:
*I hereby certify the PT license and information I have provided is true and accurate:

Contact Info

	Home / Personal	Employer Name:
*Address:		Work Address:
Add, line 2:		Work Add, 2:
*City:		Work City:
*State:		Work State:
*ZIP:		Work Zip:
Country:		Work Country:

*Phone: (xxx) xxx - xxxx		Work Phone: (xxx) xxx - xxxx
*Email:		Work Email:
Fax:		Work Fax:
Email Preference:	Home Work

PT Training Info

*University / College Name :
*State:
*Country:
*Year of PT graduation:
*Degree earned:

Other degrees:
Other certifications:

Andrews Student?	Yes No
Pacific PDPT Student?	Yes No
Manual Therapy Training or Certification?	Yes No

NAIOMT Coursework / Exam Info

*I have attended some NAIOMT core courses:	Yes No
*I have completed NAIOMT Level II (2) examination:	Yes No
*I have postprofessional clinical experience in orthopaedics of approximately:	hours.
*OCS certification:	Yes No
*Year of OCS certification:

*I would prefer the clinical component of the fellowship program take place:	at my work-site at the instructor's work site at an independent work site

*I have discussed the fellowship with the following NAIOMT faculty and/or NAIOMT Clinical Fellowship Instructors:

*The ideal time for me to start the 12 to 36 month clinical fellowship would be (projected start date):

*I prefer to be initially contacted by:	surface mail telephone email