THE NEW ENGLAND HAND SOCIETY

New England Hand Society
Membership Application for Therapists

PART I: PERSONAL DATA
Name:
  OTR PT COTA
PTA
Business address:
Home address:
Work phone:
Home phone:
Fax:
Email address:
Preferred mailing address:



You automatically qualify for membership in the NEHS if you are a:
 CHT
If you are a CHT, please enclose a photocopy of your Hand Therapy Certification credential, and skip to Part III.

PART II: PROFESSIONAL QUALIFICATIONS (Complete if not CHT)
1. Practice Requirements
Practice in Hand Therapy for a minimum of 2 years with at least 50% of caseload in upper extremity/hand rehabilitation (75% if part time). Non-direct services related to hand therapy, such as teaching or administration, will be considered.
Facility:
Dates of employment:
Hours per week:
Percent hand/upper extremity:
 %
Percent non-direct:
 %
Describe:
Facility:
Dates of employment:
Hours per week:
Percent hand/upper extremity:
 %
Percent non-direct:
 %
Describe:
Total years in practice:
 years
Total years in hand therapy (according to above requirements):
 years
2. Credentials
Undergraduate institution:
Degree/date:
Graduate institution:
Degree/date:
Registration number:
  OT PT
License number:
  OT PT
State licensed:
INCLUDE A COPY OF YOUR CURRENT LICENSE AND REGISTRATION
3. Continuing Education (past 2 years)
Conference (names and dates):
4. Presentations/Publications/Teaching Experience
Names and dates:
5. Membership in Professional Organizations
Names and dates:
6. Letter of Recommendation
Submit one letter of recommendation from a practicing hand surgeon or therapist who is a CHT.

PART III: TO BE COMPLETED BY ALL APPLICANTS
Are you currently under investigation by any professional organization or licensing board?



Have you ever had your license revoked?



If you answered yes to either of the above, please explain:
I hereby agree to comply with the constitution and by-laws of the New England Hand Society, and further agree to pay all dues and assessments promptly.
Signature:
Date:

APPLICATION DUE BY SEPTEMBER 30

Mail to:
Lois Carlson, OTR/L, CHT
Connecticut Combined Hand Therapy (A division of HOPHS)
131 New London Turnpike - Suite 319
Glastonbury, CT 06033

Please by sure to enclose:
• CHT certificate
OR, IF COMPLETING FULL APPLICATION
• License (OT/PT)
• Registration (OT/PT)

If you have questions, please call 860-652-3370 or fax 860-650-3374.

Andrew E. Caputo, M.D.
President

David M. Bass, M.D.
Vice President

David Ring, M.D.
Secretary and Treasurer

Samuel Scott, M.D.
Membership Chairman

Mary Drake
Therapist Liasion