BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
DEPARTMENT OF CONSUMER AFFAIRS • PHYSICAL THERAPY BOARD OF CALIFORNIA
2005 Evergreen St., Suite 2600, Sacramento, CA 95815
P (916) 561-8200 | (916) 561-8228 | F (916) 263-2560 | pt@dca.ca.gov
www.ptbc.ca.gov • facebook.com/ptbcnews • twitter.com/ptbcnews
LICENSE RENEWAL FORM
To renew your license, complete this form and mail it to the PTBC along with your renewal payment. Allow 3-4 weeks to process!
DO YOU HAVE AN ADDRESS AND/OR NAME CHANGE? If you do, visit the PTBC website and submit the change(s) online at least 14
days prior to mailing a license renewal payment. Licensees are required by law to notify the PTBC of any address and/or name changes
within 30 days of the change. DO NOT MAKE ANY ADDRESS AND/OR NAME CHANGES ON THIS FORM
CONTINUING COMPETENCY REQUIREMENTS: (DO NOT Complete both A & B, choose 1)
A. For Active License Status Renewal
Physical therapists and physical therapist assistants must certify they have completed all continuing competency requirements needed to
renew a license (pursuant to CCR 1399.91). Continuing competency activity must be completed within the renewal period or within the last
two (2) years, whichever occurs later. Do not submit proof of completion of continuing competency activity with this renewal form and
payment. Retain proof of completion for your records & provide to the PTBC ONLY if requested.
Continuing Competency Compliance Statement:
By signing below, I certify that I have accumulated at least the minimum continuing competency hours required by Section
1399.91 of Title 16 of the California Code of Regulations within my renewal period or within the last two (2) years, whichever
occurs later. If I am audited by the PTBC, I will submit evidence of my completion of the continuing competency hours.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS
TRUE AND CORRECT.
Signature Date
B. For Inactive License Status Renewal
If you are requesting the PTBC to place your license in an inactive status, you must check the appropriate box below. This license
status option exempts you from complying with the continuing competency requirements and prohibits you from engaging in any
activity for which a physical therapist or physical therapist assistant license is required (See CCR 1399.98)
I am requesting to place my license in an inactive status.
FOR BOARD USE ONLY
Date: Initials: RECEIPT #: ATS#: Amount: $ Check #:
License Type: Physical Therapist Physical Therapist Assistant EK EN
License Expiration date: License Number:
Name:
First MI Last
MANDATORY CONVICTION AND LICENSE DISCIPLINED DISCLOSURE QUESTION:
Since you last renewed your license, have you had any license disciplined by a government agency or other disciplinary body? Have
you been convicted of or pled guilty or nolo contendere to any felony, misdemeanor, or other criminal offense under the laws of any
state, the United States, or a foreign country, including any conviction which has been dismissed under Section 1203.4 of the Penal
Code? If you are awaiting judgment and sentencing following entry of a plea or jury verdict, you must still disclose the conviction.
Please note disclosure of this information is mandatory pursuant to Section 2644(b), Business and Professions Code.
*Yes No
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE
AND CORRECT.
Signature Date
*If you answered yes to this question, please provide details. If you have had a license disciplined, provide copies of the disciplinary order and
any documentation of rehabilitation to the PTBC. If you have been convicted, please provide CERTIFIED TRUE COPIES of the court and
arrest records for each criminal offense to the PTBC. Mail all documents within 30 days to: PTBC 2005 Evergreen Street, Suite 2600,
Sacramento, CA 95815
If you had a license disciplined, list the state(s) in which your license was disciplined:
