Orthotists and Prosthetists Supervision Agreement Sample Contracts
ContractOrthotists and Prosthetists Supervision Agreement • October 12th, 2016
ORTHOTISTS AND PROSTHETISTS SUPERVISION AGREEMENT INSTRUCTIONS Licensed Assistants, Registered Technicians, and Registered Students must be supervised by a Texas licensed practitioner currently licensed in the same discipline as the assistant, technician or student.All information provided must be typed or printed in black ink. Section 1 is to be completed by the applicant. Section 2 is to be completed by the supervisor. The applicant should return the completed form with the rest of the completed application to the address at the top of this page. PART 1 MUST BE COMPLETED BY THE APPLICANT1. APPLICANT NAME – Write your legal name in the spaces provided. (Last, First, Middle Name, Suffix) Examples of a suffix include Jr., Sr., and II. (Mr. is not a suffix.)2. SOCIAL SECURITY NUMBER – Social Security number disclosure is required by Section 231.302(1) of the Texas Family Code in order to obtain a license. Your social security number is subject to disclosure to an agency authorized to ass