Each participant must complete and submit this form to receive CEU credit and the CCIP credential. Name: * Date of Birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 APTA ID Number: Non-members leave blank. E-Mail Address: * Address: * Certificates will be sent to your address on file at APTA. Please verify that your address is correct by visiting https://www.apta.org/AptaLogin.aspx and update as needed. Selecting the URL will cause the browser to refresh. If you need to update your mailing address with APTA, it's recommended you copy and paste the URL into a new browser. City: * State: * Zip: * Professional Designation: * PT PTA Non-PT Provider Other (please specify) Professional Designation: Other (please specify) Date graduated from an accredited PT/PTA program: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Highest Degree Earned: * Associate Degree (AA/AS) Baccalaureate/Certificate Professional Master's (MPT/MSPT) Professional Doctorate (DPT) Post-professional Transition DPT Post-professional Doctorate (PhD/EdD/ScD) Number of years working as a clinician: * Number of years supervising students: * Number of students supervised in the last 5 years: * 0 1-2 3-5 6-10 11-20 More than 20 State(s) in which licensed: * You must email a copy of your state practice license(s) to cme@dmu.edu. Do you grant permission for APTA to release your contact information for RESEARCH purposes? * Yes No Do you grant permission for APTA to release your contact information for MARKETING purposes? * Yes No If necessary, please specify any special accommodations you require to complete this program: * Employer: * Employer City/State: * Employer Zip Code: * Employment Dates: * Leave this field blank
