NAIOMT/Messiah University Orthopedic Residency Program Application Question Title * 1. Residency Applicant Information Name (please include credentials, ie. PT, DPT, ATC, etc.) Company Home Address Home Address 2 City/Town State/Prov -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address (personal not work email) Phone Number Question Title * 2. List your credentials (ie. PT, DPT, etc) Question Title * 3. Enter Birth Date Date Date Question Title * 4. CLICK HERE to read the Residency Program admission requirements. I acknowledge I have read the Residency Program admission requirements. Question Title * 5. How did you hear about us? NAIOMT course Messiah University Conference - CSM Conference - AAOMPT Conference - Orthopedic Section Colleague APTA Search Internet/social media Employer Other (please specify) Question Title * 6. What PT school did you graduate from? Question Title * 7. Please provide a one paragraph biography below (name, credentials, PT school, date of graduation, current pending employment name and location and other professional information. Question Title * 8. Graduation date Date / Time Date Question Title * 9. Highest degree awarded MSPT BSPT DPT Question Title * 10. Are you an APTA member in good standing? Note: You must be a current APTA member in good standing prior to, and for the duration of the residency training. Yes No Question Title * 11. What is your APTA membership number? Question Title * 12. Are you a member of AAOMPT? Yes No If you answered "yes" to this question, please provide your membership number. Question Title * 13. Do you currently have, or have ever had, an ABPTS Certification? Yes No If you answered "yes" to this question, what ABPTS do you, or did you, hold? Question Title * 14. Do you have other certifications or training (check all that apply) Dry Needling Instrument-assisted certification CSCS CMPT COMT PhD DsC/ScD or EdD ATC CFMT CHT MTC None of the above Other (please specify) Question Title * 15. Have you taken any NAIOMT courses? Note: COMT 1-5 courses must be re-taken during ACTIVE enrollment in the NAIOMT/Messiah University Orthopedic Residency Program. Yes No If you answered "yes" to this question, what NAIOMT courses have you previously taken? Question Title * 16. PT Licensure State Question Title * 17. PT License # Question Title * 18. PT License Expiration Date Date Date Question Title * 19. Please provide the name, email address and phone number of 3 references. [first name, last name/phone number/email address] Reference #1 Reference #2 Reference #3 Question Title * 20. Do you have a conviction record or pending charges? Yes No If you answered "yes", please provide details below. Question Title * 21. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? Yes No Question Title * 22. Have you ever had any license, certificate, registration, or other privilege to practice a health care profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? Yes No Question Title * 23. Have you ever surrendered a credential in connection with, or to avoid, action by a state, federal, or foreign authority? Yes No Question Title * 24. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? Yes No Question Title * 25. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of a health care profession? Yes No Question Title * 26. If you answered “yes” to any of the questions (17-22), the comments box below provides an option to explain the circumstances. Question Title * 27. Current Employer Name Advanced Kinetics Physical Therapy and Sports Performance Marathon Physical Therapy and Sports Performance PRN Physical Therapy Phoenix Physical Therapy Other (please specify) Question Title * 28. Employer Information Name of Supervisor * Company * Address * Address 2 City/Town * State/Prov * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Country * Employer/Supervisor's Email Address * Employer/Supervisor's Phone Number * Question Title * 29. Have you negotiated participation in the NAIOMT/Messiah University Orthopedic Residency Program with your employer? *NOTE – Participants in this residency must be employed by one of our clinical practice partners at an ABPTRFE-approved site. Yes No Question Title * 30. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, and/or medications whether taken legally or illegally Yes No Question Title * 31. Are you currently engaged in the illegal use controlled substance(s)?“Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or according to the directions of a licensed health care practitioner. Yes No Question Title * 32. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? Yes No Question Title * 33. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism, or frotteurism? Yes No Question Title * 34. Upload your CV PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File No file chosen Remove File Upload your CV Question Title * 35. Upload a one paragraph biography. Include your school and professional history and what you like to do in your time outside of work. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File No file chosen Remove File Upload a one paragraph biography. Include your school and professional history and what you like to do in your time outside of work. Question Title * 36. Upload a head and shoulder photo in JPG format. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File No file chosen Remove File Upload a head and shoulder photo in JPG format. Question Title * 37. I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for the residency program. Yes Question Title * 38. Please enter date Date / Time Date Page1 / 1 100% of survey complete. Submit