Emory University Division of Physical Therapy
1462 Clifton Road, Suite 312
Atlanta, Ga. 30322
Application deadline: October 1, 2010
Legal name: ___________________________ ____________________ __________________
Last First Middle
Date of birth:___________________ Male Female
Number and street Apt number
____________________________ ______________ __________________
City State Zip Code
Home Telephone: ( ______ ) _________________________
Cell Phone: ( _____ ) ____________________________
E-mail address: ___________________________________
What is your highest academic degree? _________________________________
Please list the titles of previous research projects and the school/institutional affiliation:
Do you hold a current license to practice Physical Therapy in Georgia? Yes No
If no, when do you anticipate obtaining your Georgia PT license? _________________
Do you hold licenses to practice physical therapy in other states? ___________________
Do you have other board specialty certifications? Yes No
If yes, please list other board specialty certifications and the date of certification:
Name of college Year(s) Degree Major Graduation Date
Please list two positions that you have held within the last five years:
Position Employer Dates
RESIDENT’S STATEMENT OF INTEREST
Please answer the following questions and submit with the Emory Orthopedic Residency
Application. Your answers should be submitted in type-written format, double spaced.
1. Why have you chosen to apply to the Emory Orthopedic Residency Program?
2. What are your personal professional goals and objectives?
3. How do you feel that this program will assist you in meeting your personal goals and
4. Through the achievement of you personal goals, how do you envision your
role/contribution to the physical therapy five years from now?
I certify that the above information that will be submitted to the Emory University, Division of
Physical Therapy is correct to the best of my knowledge.
Signature of applicant Date