Candidate Profile For Physical Therapist: Personal

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CANDIDATE PROFILE

For PHYSICAL THERAPIST

PERSONAL :

Profession: _______________________________ Date: Completed:________________________

Name (Last, First, Middle): _____________________________________________________________

Date of Birth: ___________________ Place and Country of Birth: ____________________________

Gender: Male ______ Female:_______ Status: Single:____ Married:____ Separated:____

Mother’s Maiden Name: _______________________________________________________________

Current Home Address:________________________________________________________________

Contact Information: Cell phone _______________ Landline:_____________________________

Email Address:_______________________________________________________

Passport: (Yes or No) : If Yes, provide Passport No. _______________Expiration Date:_____________

(Note: provide Medpro Overseas Coordinator clear copy of passport)

Place of Issue:_______________________________________________________________________

EDUCATION:

Name of School where Bachelor’s Degree was obtained: ______________________________________

Complete School Address: _______________________________________________________________

Month , Day and Year of Graduation:______________________________________________________

Name of School where Secondary education was obtained: ____________________________________

Complete School Address:


_____________________________________________________________________

Month, Day and Year of Graduation:_______________________________________________________


LICENSURE/VISA SCREENING:

Original Country of Licensure: ____________________________________________________________

License No: _____________ Issuance Date: _________________ Expiry Date: _______________

Initial State of Licensure: (U.S., /other Countries if available) ___________________________________

License No: _____________ Issuance Date: _________________ Expiry Date: _______________

License No: _____________ Issuance Date: _________________ Expiry Date: _______________

If with FSBPT- Alternative Identification Number (AIN ) pls. provide:___________________

TOEFL IBT

Date of Exam:__________________________ (IF TAKEN)

ETS account: Username:____________________________; Password:___________________________

itemized Scores: Reading:______; Writing:_________; Speaking:________; Listening:____________

Visa Screen Type: (pls. Check) : FCCPT ___ CGFNS-ICHP_____

If availed from FCCPT, provide FCCPT File No.______________

If Availed from CGNS, provide CGFNS ID No., Username and Password

Issuance Date: _____________________ Expiry Date: __________________________

EMPLOYMENT HISTORY

Current Employer: ________________________________________________________

Complete Name and Address:_______________________________________________

Position Held:___________________________________________________________

Period of Employment:_____________________________________________________

Previous Employer:_______________________________________________________

Complete Name and Address:_______________________________________________

Period of Employment:____________________________________________________
Position Held:___________________________________________________________

IMMIGRATION:

Visa Classification (pls. check) B1B2:____; H1B:_____; EB3:_____

Passport No.____________ (if available) Validity Date:___________

Have you applied for B1/B2 Visa? (Yes)_________ (No)___________

Date of Interview: ______________________________________________________

Result : Granted( Yes/No)___________ If YES : indicate validity Date:____________

Have you been petitioned for H1B (Working Visa) (Yes) _______ (No)_______

Date of Interview:________________________________________________________

Result : Granted( Yes/No)___________ If YES : indicate validity Date:____________

If granted H1B Visa in the past: Provide copies of INS receipt , approval, denial notices.

Have you been petitioned for EB3/EB2 (Immigrant –Employment/Family Based) (Yes) _______
(No)_______

Status of EB3/EB2 Case:______________________________________________________

Provide copies of INS receipt notice; Approval Notice or Denials.

If with Relatives in the U.S. , provide complete Name , Address and contact Nos.

Name:______________________________________________________________

Complete Address in the U.S.___________________________________________

Landline:_______________________________ Cellphone:__________________

LIST OF DEPENDENTS (EB2 Filing)

Last Name First Name Date of Birth Country of Birth Relationship to Beneficiary

___________ ____________ ___________ _______________ ______________________

___________ ____________ ___________ _______________ ______________________

___________ ____________ ___________ _______________ ______________________


___________ ____________ ___________ _______________ ______________________

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