Mississippi Board of Physical Therapy
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Course Sponsor Prior Approval               


Please Note: This form is only for use with an online payment.
If you do NOT plan to pay online, do not use this form. Fill out the paper form and mail it with your payment.
*Required Fields 
*1. Course Title:
      *Date(s):
      *Duration (hours):
*2. Location(s)
*3. Sponsoring Organization:
      *Address:  
      *City:  
     *State:
      *Zip:  
*4. Course Instructor(s) for this course only:
*5. Course Instructor Background Information (i.e. education and instruction experience only)

Upload resume or CV:
*6. Specifically, how will monitoring of course participation and completion be dealt with?
*7. Course Agenda/Instructional Timeline:
*8. Course Objectives:
*9. Course Description:
*10. Please indicate if this continuing competence activity has been approved for credit by any professional organizations. (please list)
*11. Is this course being offered to professionals outside the sponsoring organization?   
12. Please give a name, address and phone number of a contact person who can provide information concerning this activity.
*Name
*Address
 Address 2
*City
*State
*Zip
*Phone
*Email
Any CC information, forms and brochures that are required can be uploaded by being combined into 1 PDF that is not more than 5Mbs. If your PDF is larger than this please email or mail to the board office address below.
The sponsor should be aware that the course is being approved for a one year period from July 1 to June 30.
 
When you submit this form you will be taken to the payment screen.

If you have any questions regarding this form, you may call 601-352-2918.
Transaction Number: 234420216
234420216

Mississippi Board of Physical Therapy Website Disclaimer
Mississippi State Board of Physical Therapy
P.O. Box 55707
Jackson, MS 39296-5707
Phone: (601) 352-2918
Fax: (601) 352-2920
Email: SBoyette@msbpt.ms.gov
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