Emory University
Orthopedic Physical Therapy Residency Program
Emory University Division of Physical Therapy
Admissions Office
1462 Clifton Road, Suite 312
Atlanta, Ga. 30322
Attn: Kathleen Geist, PT, DPT, OCS, COMT□
APPLICANT INFORMATION:
Application deadline: February 1, 2013
Legal name: ___________________________ ____________________ __________________
Last
Date of birth:___________________

First
Male

Middle
Female
Current address:
_________________________________________________
Number and street
Apt number
____________________________ ______________
City
_________________________
State
__________________
Zip Code
Home Telephone: ( ______ ) _________________________
Cell Phone: ( _____ ) ____________________________
E-mail address: ___________________________________
EDUCATIONAL BACKGROUND
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
Emory University
Orthopedic Physical Therapy Residency Program
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
attended:
college Year(s)
Attended
Degree
Major
Graduation Date
List professional licenses and specialty certifications
WORK EXPERIENCE:
Please list two positions that you have held within the last five years (if applicable):
Position
Employer
Dates
______________________________________________________________________________
RESIDENT’S STATEMENT OF INTEREST
Emory University
Orthopedic Physical Therapy Residency Program
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
objectives?
4. Through the achievement of your 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 Division of Physical Therapy,
Emory University School of Medicine is correct to the best of my knowledge.
________________________________________________
Signature of applicant
________________
Date