Your negotiating team would like to learn more about your education and certifications to represent you effectively during negotiations. Please complete this survey ASAP.

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* 1. First Name

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* 2. Last Name

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* 3. Personal Email

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* 4. Cell Phone

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* 5. Home Phone

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* 6. Degree Obtained

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* 7. Which, if any, of the APTA Board Certification(s) do you hold?

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* 8. Which, if any, of the AOTA Board Certification(s) do you hold?

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* 9. Which, if any, of the Practitioners Specialty Certification(s) do you hold?

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* 10. Which, if any, additional certifications do you hold?

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