BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
CALIFORNIA BOARD OF OCCUPATIONAL THERAPY
2005 Evergreen Street, Suite 2250, Sacramento, CA 95815-3831
T: (916) 263-2294 F: (916) 263-2701
E-mail:
cbot@dca.ca.gov
Web:
APPLICATION FOR RETIRED STATUS
In order to process your request, please complete all sections of this form, sign, date and
submit to the California Board of Occupational Therapy at the above address along with a fee of
$25.Your request must be postmarked prior to the expiration of the license.
1. ADDRESS VERIFICATION
Name
OT/OTA # __________
_______________________________________
Please circle one
Address of Record ___________________________________________________
City, State ________________________
Zip Code ____________________
Contact Number (______)_____________________
Please note: If the above address is not your address of record, you must also submit an Address
Change Request form.
2. TERMS AND CONDITIONS
In accordance with section 4128(c)(d)(e) a license in retired status is not subject to renewal; the
holder of a license in retired status shall not engage in any activity for which an active license is
required. An occupational therapist holding a license in retired status shall be permitted to use
the title “occupational therapist retired” or “retired occupational therapist”. An occupational
therapy assistant holding a license in retired status shall be permitted to use the title
“occupational therapy assistant retired” or “retired occupational therapy assistant”. The
designation of retired shall not be abbreviated in any way. Failure to comply with these terms
and conditions is unprofessional conduct and grounds for citation or discipline.
3. CONVICTION/DISCIPLINE
Have you been convicted of or pled guilty or nolo contendere to any misdemeanor or felony,
whether or not the conviction has been dismissed, or been disciplined by another public agency
in this or any other state, subsequent to your last renewal? (If you select YES, please indicate
circumstances and court, and send copies of the court documents to the Board, if available.)
NO
Yes
Nature of Conviction & Court ______________________________