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Application Request



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1.   License Request type    (Select one) **Required
  Initial (select this option if you have never held a license in NH)   
Reinstatement (select this option if you have held a license in NH in the past)   
 
2.   Profession (Select one) **Required
 
 
3.   Last Name    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
4.   First Name    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
5.   Middle Initial    (Type Answer)
 
(1 character limit; 1 remaining.)
 
6.   Mailing Address    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
7.   City    (Type Answer)
 
(100 character limit; 100 remaining.)
 
8.   State (Select one)
 
 
9.   Zip    (Type Answer)
 
(100 character limit; 100 remaining.)
 
10.   Phone Number Where You Can Be Reached    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
11.   E-Mail Address    (Select one) **Required
  email      I do not have an e-mail address   
 
12.   What state are you currently practicing in    (Select one) **Required
  State      I am not currently practicing    I am a new graduate   
 
13.   What is the last date you practiced    (Select one) **Required
  Date (DD/MM/YYYY)      I am currently practicing    I am a new graduate   
 
14.   I have been foreign trained send me an application for PT/PTA Exam    (Select one)
  Yes    No   
 
15.   Send me the form for SLP provisional license    (Select one)
  Yes    No   
 
16.   Send me an application for temporary licensure Additional fee of $100 is required (only available to PTs at the present time) Only for those holding a license in good standing in CT, MA, ME, NY, RI, and VT    (Select one) **Required
  Yes    No   
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