FELLOWSHIP SPORTS & ORTHO MANUAL THERAPY

FELLOWSHIP IN SPORTS & ORTHOPEDIC MANUAL THERAPY

Thank you for taking your first step towards clinical excellence. Please complete all components of this form to avoid delays in the review process.
First Name*
Middle Name
Last Name*
NAME

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EMAIL (personal email recommended)*
Phone Number*

Area CodePhone Number
EMPLOYER*
YEARS OF EXPERIENCE*
If student, please indicate anticipated graduation date:
APTA MEMBER NUMBER (if available)
REFERRAL SOURCE*

IAR FACULTY / STUDENTIAR WEBSITEAPTA / TPTAE-NEWSLETTERSOCIAL MEDIAOther
IF REFERRED BY IAR FACULTY/STUDENT, PLEASE IDENTIFY THIS INDIVIDUAL*
HAVE YOU COMPLETED A CERTIFICATION COURSE/PROGRAM SPECIFIC TO MANUAL THERAPY*

YESNO
IF YES, PLEASE ENTER NAME OF COURSE/PROGRAM AND GRADUATION YEAR
ARE YOU A GRADUATE OR SOON TO BE GRADUATE OF AN APTA ACCREDITED RESIDENCY PROGRAM?*

YESNO
IF YES, PLEASE ENTER NAME OF RESIDENCY PROGRAM AND GRADUATION YEAR
ARE YOU CURRENTLY AN ABPTRFE BOARD CERTIFIED SPECIALIST (ie OCS or SCS)*

YESNO
IF YES, PLEASE ENTER SPECIFIC CERTIFICATION CREDENTIAL AND YEAR EARNED
IAR reserves the right to confirm applicant's previous certifications and graduations.
BRIEFLY TELL US WHY YOU ARE INTERESTED IN BEING PART OF THE IAR TEAM. ANY INTERESTING FACTS ABOUT YOU THAT MAY HELP US DURING THE REVIEW PROCESS IS GREATLY APPRECIATED. *
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FELLOWSHIP IN SPORTS & ORTHOPEDIC MANUAL THERAPY