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Get APTA CCIP Participant Dossier 2012

T Name: Current Address: E-Mail Address: I am a (please check): DOB: City: Phone (H): PT Are you an APTA member: No Number of years as a clinician: Type of entry-level degree: Highest earned degree: State(s) in which licensed: PTA State: Phone (W/C): Zip: Non-PT Provider – (if yes, please specify): Yes – (If yes, please provide ID number): Number of years supervising students: Date graduated from an accredited PT/PTA Program: Baccalaureate/Certificate Professional Master's (MPT/M.

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