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Nevada State Board of Physical Therapy Examiners

7570 Norman Rockwell Lane Suite 230

Las Vegas, NV 89143

(702) 876-5535

Physical Therapy - $150.00

Physical Therapist Assistant $100.00

Make all payment payable to: Nevada State Board of Physical Therapy

To receive your renewal certificate, you must submit this completed form (both pages) and pay the required fee

postmarked no later than July 31, 2017. Your original current license must be displayed on August 1, 2017. You may

renew your license if you are not presently working by checking the appropriate box below, completing this form, and

paying the renewal fee.

Be certain to answer all questions on the form including the Continuing Education requirement section. This education

must be obtained between the dates of August 1, 2016 and July 31, 2017. Fraudulently representing, or failure to obtain

continuing education as represented on this renewal/continuing education form could result in disciplinary action.

Please verify the primary professional address and personal information set forth below, making correction if

necessary. Primary professional address means the physical address where a license practices physical therapy or carries

out any other activities relating to physical therapy for the majority of his working hours. Post Office Box addresses are not

acceptable.

Failure to renew your license will result in the expiration of the license effective August 1, 2017. You will need to be

reinstated before you may practice in the State of Nevada.

I do not intend to renew my license.

Name:

License #:

Address:

SS #:

Home Phone:

DOB:

Cell Phone:

Home Fax:

Email:

I am not presently

Professional

working

Address:

Telephone #

Fax #

It is required for this portion of the renewal Child Support Information: Please mark the appropriate

response (failure to mark one of the three will result in denial of the application):

I am not subject to a court order for the support of a child

I am subject to a court order for the support of one or more children and am in compliance with the order or

am in compliance with a plan approved by the district attorney or other public agency enforcing the order for

the amount owed pursuant to the order, or:

I am subject to a court order for the support of one or more children and am not in compliance with the order

or a plan approved by the district attorney or other public agency enforcing the order for the repayment of

the amount owed pursuant to the order.

Renewal Certificate Receiving Form - Nevada State Board Of Physical Therapy Examiners

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