FSBPT Volunteer Application
 
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  Directions: To be considered, please fill out this form and send a copy of your resume or curriculum vitae to:

FSBPT Volunteer Application
Federation of State Boards of Physical Therapy
124 West Street South
3rd Floor
Alexandria, VA 22314
Fax: 703-299-3110
ATTN: Assessment Department
E-Mail: volunteer@fsbpt.org

You may submit your resume or CV via e-mail, please make sure the subject of the e-mail reads "Volunteer Application".
 
 
 
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3.
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(Please use abbreviations e.g. IN for Indiana)
 
 
 
 
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8.

 
 
 
 
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12.
Please tell us in which areas you are interested in volunteering. Check all that apply.*
 
   
NPTE - PT  
NPTE - PTA  
Practice Review Tool  
 
 
 
13.
Please list the states where you currently hold an active license.*
(Please use abbreviations e.g. IN for Indiana)   Enter at least 1 response.
 

 

 

 

 
 
 
 
14.
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  mm/dd/yyyy
 
 
 
  In order to develop a group of volunteers that is representative of the physical therapy profession; please provide the following information:
 
 
 
15.
Gender (optional):
 
 
 
 
16.
Professional Level:*
 
 
 
 
 
17.
Race/Ethnicity (optional):
 
 
 
 
 
       
 
 
 
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21.

 
 
 
 
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23.
If yes, on what committee and in what year did you serve?
 

 

 
 
 
 
24.
Please indicate your primary practice setting with a "1". Indicate second and third practice setting with a "2" and "3" if needed. Please list no more than 3 practice settings.
Rank the items below, using numeric values starting with 1.
 

 

 

 

 

 

 

 

 

 
 
 
 
25.

 
 
 
 
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28.
What is your primary area of expertise?*
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
       
 
 
 
29.
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The value must be between 0 and 100, inclusive.
 
 
 
 
30.
What is your secondary area of expertise?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
       
 
 
 
31.
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The value must be between 0 and 100, inclusive.
 
 
 
 
32.
What is your tertiary area of expertise?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
       
 
 
 
33.

The value must be between 0 and 100, inclusive.
 
 
 
 
34.
*
The value must be between 0 and 100, inclusive.
 
 
 
 
35.

PTs Only   The value must be between 0 and 100, inclusive.
 
 
 
  Done   Cancel