AAMT Fellowship Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

What year did you graduate PT School?

How many years of outpatient orthopaedic PT clinical experience do you have?

What state(s) are you licensed to practice in?

Although not required, have you completed an APTA credentialed residency program?

Yes

If YES to above, which program?

Although not required, are you a Board Certified Specialist through ABPTS?

OCS

SCS

NCS

What courses have you already completed through Spinal Manipulation Institute and/or Dry Needling Institute?

Please list any certifications or manual therapy continuing education classes that you have taken in the last 5 years.

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