Application to Attend MTI

The Manual Therapy Institute

M T I

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Mission Statement

Admission Standards

Fellowships

Residency vs Fellowship

Clinical Mentoring

What Mentors Provide

Factors To Consider

What Fellows Seek

Midwestern Sites

Course Info

Course Descriptions

Course Locations

Course Schedules

Course Materials

Merchandise

Application to Attend MTI


Contact Information
	Applying for location
	Your name
	Facility name
	Work address
	Work City, State, Zip
	Work phone
	Home address
	Home City, State, Zip
	Home phone
	Mobile phone
	E-mail Address

Employment Information
	Current position/title
	# Years as practicing PT
	# Years practicing in orthopedic PT
	# Years practicing with company

Basic Physical Therapy Education
	Date completed
	Name of institution
	Degree initials

Advanced Education
	Date completed
	Name of institution
	Degree initials

Manual Therapy Education
	Please list all post-professional courses in the areas of orthopedics and manual therapy.
	Course Sponsor		Course Title	Course Date





Specialization
	Are you board certified by the American Board of Physical Therapy Specialties?
			YesNo
	If yes, area of specialty

License
	List the state license number and expiration date for your current license(s) to practice PT. Check the state in which you are currently practicing.
	State		Practicing
	License #
	Expiration date