ORTHOPEDIC PT RESIDENCY PROGRAM APPLICATION

APPLICANT INFORMATION Legal Name: ___________________________________________ Date of Birth: _________________________ Current Address: _______________________________________________________________ _____________________________________________________________________________ Permanent Home Address: _______________________________________________________ _____________________________________________________________________________ Permanent Home Telephone: _________________________ Cell Phone: _________________ E-mail Address: ________________________________________________________________ START DATE January 2nd August 1st APPLICATION DEADLINE September 1st April 1st Male __ Female __

You must be licensed prior to starting the program in August 1 or January 2. I certify that the information on the Application is correct to the best of my knowledge.

Signature of Applicant: ________________________________________ Date: _____________

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EDUCATIONAL BACKGROUND What is your highest academic degree: _____________________________________________ If you have completed a Masters degree, was an independent research project required? Yes __ No __ If yes, please state the title of your research project: __________________________________ Are you currently licensed to practice physical therapy in the State of California? Yes __ (Please include a copy of your license with your application) No __ If you are not yet licensed, are you eligible for your licensure in the State of California? Yes __ No __ If yes, when do you anticipate receiving licensure in the State of California? Are you board certified in a clinical specialty? Yes __ No __ If yes, give the specialty and date of certification: ____________________________________________________________________________

COLLEGES/UNIVERSITY ATTENDED Name of Colleges Attended Year(s) Degree/Certificate Attended Major Graduation Date

WORK EXPERIENCE List the three (3) most recent positions you have held: Position (Title) Employer Dates

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PERSONAL STATEMENT The personal statement should be typed and double spaced. Please use the following questions as related to your clinical/academic circumstance to assist in the preparation of your personal statement. 1. 2. 3. 4. 5. Why have you chosen to apply for admission to the Physical Therapyworks Residency Program? What is the area of your current research or clinical interest? What are your professional goals or objectives? How do you plan to accomplish these goals? How do you consider this program will facilitate the accomplishment of your professional goals? 6. By achievement of your professional goals, how do you feel you may contribute to the field of physical therapy and/or the science of movement? 7. Describe your clinical experience as a physical therapist.

LETTERS OF RECOMMENDATION Please download the Recommendation Form (pdf) from our website under Residency at PTW, How to Apply: www.physicaltherapyworks.com Among those writing your recommendations, you must include the following: 1. a current or former supervisor (if a recent graduate, from a current or former clinical instructor) 2. an instructor/faculty member from an accredited physical therapy program and/or a physician with whom the physical therapist has worked in the past. A total of three (3) Recommendation forms must be sent to us by your chosen Recommenders either by email, fax, or regular mail. Physical Therapyworks Orthopedic Residency Program 719 Santa Monica Blvd, Santa Monica, CA 90401 Phone: (310) 260-9039 Fax: (310) 260-1091 Email: john@physicaltherapyworks.com

Please list the names and addresses of the Recommenders to whom you have sent the Recommendation Forms to. Name Address/City/State Telephone Email Address

APPLICATION PROCEDURES Please submit the following documents in ONE PACKET to Physical Therapyworks (see address on page 3). 1. This application 2. Official transcripts from each college or university attended (Transcripts must be in a sealed envelope). 3. A Personal Statement. 4. Current curriculum vitae (CV) or resume. 5. Copy of your California Physical Therapy License. 6. Recommendation Forms must be sent to us either by you or by your recommenders in a sealed envelope. The Recommendation Forms may also be sent by email or fax from the recommenders. Applicants are required to have a personal interview. You will be notified at a later date regarding the interview. If you have any questions regarding the application or about the program, please contact the Program Director/Coordinator: John Dravillas, PT, MTC, OCS at: (310) 260-9039.