CLINIC STARTUP INCUBATOR APPLICATION FORM Lorem ipsum dolor sit amet, consectetur adipiscing elit. Morbi consectetur, ipsum sit amet lacinia euismod, nisi leo dignissim nulla, non consequat justo nisl sed dolor. Cras diam nisl, fermentum eu semper quis, dignissim non arcu. Pellentesque posuere rutrum orci eu euismod. Please complete the application form below by providing the requested information. Additionally, if possible, include a letter of recommendation from a former manager or instructor. This letter should address the following points: ● The practice setting in which they have worked with you. ● The years during which they worked alongside you. ● The frequency of your interaction with them (e.g., daily, monthly, every 2-3 months, annually, etc). Furthermore, please complete and attach a background check report. Name* First Middle Last Email* Phone*How many years of experience do you have practicing full-time in an outpatient physical therapy setting?*Year of fellowship completion and fellowship program completed* Anticipated completion accepted if prior to incubator cohort start date. Enter N/A if you are pursuing or have completed a fellowship.Are you a member of the American Academy of Orthopedic Manual Physical Therapists?*Are you a member of the American Academy of Orthopedic Manual Physical Therapists?* Yes No State(s) of interest for your physical therapy business startup *State(s) of interest first choice*AlabamaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState(s) of interest second choiceAlabamaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState(s) of interest third choiceAlabamaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWhat are your goals for your physical therapy business?*What interests you about running your own physical therapy business?*Please list any specialist certifications that you have achievedHow did you hear about the program?*Fellowship programPT schoolEmployerOtherPlease expand Documents to uploadResume*Max. file size: 10 MB.Please attach your resume.PT School transcript*Max. file size: 10 MB.The transcript should include the graduation year, and final PT degree awarded directly from school.Background check report*Max. file size: 10 MB.Please complete and attach the background check reportRecommendation letterMax. file size: 10 MB.Please attach a recommendation letter.Notwithstanding anything to the contrary in this document or in any other materials related to the program, no individual will be eligible to join or remain in the program until he or she has passed all pre-employment examinations, drug testing, and other screenings or prerequisites that may be imposed by Accelacare from time to time, in its sole discretion.
