Improving Outcomes for People with Disabilities: Occupational Therapy, Physical Therapy, and Athletic Trainers Board (OTPTAT) CEU Credit Intake Form

OTPTAT requires reporting of this information. Please fill out this form completely if you intend to apply for OTPTAT CEU credit.
1.Last Name
2.First Name
3.Address
4.Address 2
5.Address 3
6.City
7.State
8.Zip Code
9.Country
10.Email
11.ID Number

Enter this information if you have a unique ID number, otherwise leave blank
12.Please select the sessions that you attended (check all that apply):
13.OTPTAT CEUs
Number of CEUs being applied for