PHYSICAL REHABILITATION APPLICATION Checklist and Attestation Checklist of Application Items Applicant Information Reflective Portfolio—Criterion 9 Employment/Volunteer Verification Form(s) Reflective Portfolio—Criterion 10 Reflective Portfolio—Criterion 1 Reflective Portfolio—Criterion 11 Reflective Portfolio—Criterion 2 Reflective Portfolio—Criterion 12 Reflective Portfolio—Criterion 3 Reflective Portfolio—Criterion 13 Reflective Portfolio—Criterion 4 Self-Assessment Reflective Portfolio—Criterion 5 Professional Development Goal 1 Reflective Portfolio—Criterion 6 Professional Development Goal 2 Reflective Portfolio—Criterion 7 Professional Development Goal 3 Reflective Portfolio—Criterion 8 Item(s) to Submit The following should be sent to by the application deadline. A single combined document, preferably PDF, is encouraged: Certification Application (this document) Employment/Volunteer Verification Form All professional activity development forms Any additional evidence as required by a particular activity (e.g., CE certificates) Application fee of $525 (submitted separately from application): Credit card: Call (800) SAY-AOTA (800-729-2682) extension 1708 Monday- Friday between 9:00-5:00 Eastern to pay by Mail check on or before the application deadline to Check: AOTA—Attn: Certification 4720 Montgomery Lane Bethesda, MD Applicant Attestation I hereby attest that the information provided in this application is my own and that I have complied with all Occupational Therapy Code of Ethics and Ethics Standards, including Beneficence; Nonmaleficence; Autonomy, Confidentiality; Social Justice; Procedural Justice; Veracity; and Fidelity. If granted certification, I will not use my credential to represent myself to others beyond the level for which I am qualified. Signature (electronic signature acceptable) Date
PHYSICAL REHABILITATION APPLICATION Checklist and Attestation Checklist of Application Items Applicant Information Employment/Volunteer Verification Form(s) Reflective Portfolio—Criterion 1 Reflective Portfolio—Criterion 2 Reflective Portfolio—Criterion 3 Reflective Portfolio—Criterion 4 Reflective Portfolio—Criterion 5 Reflective Portfolio—Criterion 6 Reflective Portfolio—Criterion 7 Reflective Portfolio—Criterion 8 Reflective Portfolio—Criterion 9 Reflective Portfolio—Criterion 10 Reflective Portfolio—Criterion 11 Reflective Portfolio—Criterion 12 Reflective Portfolio—Criterion 13 Self-Assessment Professional Development Goal 1 Professional Development Goal 2 Professional Development Goal 3 Item(s) to Submit The following should be sent to by the application deadline. A single combined document, preferably PDF, is encouraged: Certification Application (this document) Employment/Volunteer Verification Form All professional activity development forms Any additional evidence as required by a particular activity (e.g., CE certificates) Application fee of $525 (submitted separately from application): Credit card: Call (800) SAY-AOTA (800-729-2682) extension 1708 Monday- Friday between 9:00-5:00 Eastern to pay by Check: Mail check on or before the application deadline to AOTA—Attn: Certification 4720 Montgomery Lane Bethesda, MD Applicant Attestation I hereby attest that the information provided in this application is my own and that I have complied with all Occupational Therapy Code of Ethics and Ethics Standards, including Beneficence; Nonmaleficence; Autonomy, Confidentiality; Social Justice; Procedural Justice; Veracity; and Fidelity. If granted certification, I will not use my credential to represent myself to others beyond the level for which I am qualified. Signature (electronic signature acceptable) Date
BCPR-Part-1-APPLICATION.docx