NAIOMT > Exam Registration Info Request

NAIOMT Level I, II Course Registration Request


	Please read the NAIOMT Privacy Policy.

Detailed instructions and passwords will be sent to candidates and proctors a week before the exam.

Please note: online registration is a two step process.
1) Click a link below to provide us your information and select exam to register for. When you have submitted this information, you will be provided a link to pay for the exam registration.
2) Pay for your exam registration.
Exam registration is not complete until payment is received!

Student Info

*NAIOMT ID:
	Your NAIOMT ID is your first and last initial and the last 4 digits of your social security number. For example Jane Doe whose SSN is 123-45-6789 would have a NAIOMT ID of jd6789
*Name:
Different last name (eg. Maiden):
Name desired on certificate, if applicable:

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

NAIOMT Coursework / Exam Info

Course Name:	Course Taken	Course Challenged
500 Level I Differential DX
600 Level II Upper Quadrant
610 Level II Lower Quadrant

Exam Name:	Year:	Exam Completed
Level I Online Exam
Level II LQ Exam
Level II UQ Exam

Challenging Courses/Exams: If you are pursuing examination and plan not to attend certain NAIOMT core courses, indicate which courses in the spaces above. You are required to pay a one-time $15.00 per day per course fee ($90.00 - Core courses run 6 days) for all related courses not attended at the time you register for the exam. To pay a challenge course fee, go to the "Exams" page and click the "Registration" link at the top left. Find "Follow Up Payments" section and select "Make Payment Here". Be sure to place in the comment section of the payment page that your payment is for a challenge course fee and provide the exam and course type it is pertaining to.

Select Exam

Level I	Level II UQ	Level II LQ
Not registering for L I	Not registering for L II UQ	Not registering for L II LQ
Sep 16, 2010	Sep 16, 2010	Sep 16, 2010
Nov 13, 2010	Nov 13, 2010	Nov 13, 2010
Jan 13, 2011	Jan 13, 2011	Jan 13, 2011
Jan 14, 2011	Jan 14, 2011	Jan 14, 2011
Jan 15, 2011	Jan 15, 2011	Jan 15, 2011
Feb 10, 2011	Feb 10, 2011	Feb 10, 2011
Feb 11, 2011	Feb 11, 2011	Feb 11, 2011
Feb 12, 2011	Feb 12, 2011	Feb 12, 2011
Mar 10, 2011	Mar 10, 2011	Mar 10, 2011
Mar 12, 2011	Mar 12, 2011	Mar 12, 2011
May 12, 2011	May 12, 2011	May 12, 2011
May 13, 2011	May 13, 2011	May 13, 2011
May 14, 2011	May 14, 2011	May 14, 2011
Mar 11, 2011	Mar 11, 2011	Mar 11, 2011
Jun 9, 2011	Jun 9, 2011	Jun 9, 2011
Jun 10, 2011	Jun 10, 2011	Jun 10, 2011
Jun 11, 2011	Jun 11, 2011	Jun 11, 2011
Sep 15, 2011	Sep 15, 2011	Sep 15, 2011
Sep 16, 2011	Sep 16, 2011	Sep 16, 2011
Sep 17, 2011	Sep 17, 2011	Sep 17, 2011
Oct 13, 2011	Oct 13, 2011	Oct 13, 2011
Oct 14, 2011	Oct 14, 2011	Oct 14, 2011
Oct 15, 2011	Oct 15, 2011	Oct 15, 2011
Nov 17, 2011	Nov 17, 2011	Nov 17, 2011
Nov 18, 2011	Nov 18, 2011	Nov 18, 2011
Nov 19, 2011	Nov 19, 2011	Nov 19, 2011

Proctor Info

*Proctor Name:
*Proctor Relationship :
*Proctor Phone:
*Proctor Email:

The proctor must have an individual email and mailing address separate from the candidate/s (mailing address may be the same if both are located in the same office). Both the candidate and their proctor are responsible for checking their email on a regular basis prior to the examination date as most communications from the exam coordinator prior to the exam will be via email. Candidates and proctors will be emailed or mailed confidential instructions sometime during the week prior to the examination date. NAIOMT now has a study guide with sample examination questions. Email requests for a copy of this guide to exams@naiomt.com.

With the following electronic affirmation and date to verify I agree:

I wish to apply for the examination(s) indicated above and if applicable have included the fee(s) for courses I am not taking. I understand I may choose level III exam components for different dates, but that the application deadlines for each part must be honored. Re-examinations for failed components are at 100% of the original fee and there are no academic appeals. Postponement of exams due to health reasons must be accompanied by a note from a physician and remains at the discretion of the exam coordinator. I hereby certify the information I have provided is true and accurate and I am a currently licensed physical therapist in good standing.

*Agreed

*Date