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Application form

Initial Application for the European Certified Hand Therapist Credential
Name of Applicant
Family name
First name
Date of Birth (Day/Month/Year)
Nationality
Professional information
Title
Profession
 Occupational Therapist (OT)
 Physical Therapist (PT)
Please indicate the date you graduated as OT/PT
Number of years of experience as OT/PT
Please list the Hand Therapy Society of which you are a member, and that has certified you as Hand Therapist
Please list your society membership number (if your society does not issue membership numbers please write no number)
Please indicate the date you were certified as a Hand Therapist in your country
Number of years of Hand Therapy experience
Please list the number of hours of experience you can document in Hand Therapy
Contact information
Home address
Street
City
Postal Code
Country
Workplace address (if you have more than one current place of employment, please add a line and include all contact information for your current employment situations, including the institute or department name)
Name
Street
Postal Code
City
Telephone contact information (please include the country code)
Home phone
Work phone
Cell phone
Fax / Other
E-mail contact information
E-mail address
I (applicant) hereby confirm that I have carefully read the EFSHT ECHT Candidate Handbook and feel that I will be able to meet the criteria and therefore declare my intent to begin this process. I confirm that the information presented in this application is accurate and true.
Date and location
Message
A copy of this information will be emailed to the supplied e-mailaddress