North Carolina Board Of Occupational Therapy printable pdf download

NORTH CAROLINA BOARD OF OCCUPATIONAL THERAPY

NAME/ADDRESS CHANGE NOTIFICATION FORM

Mailing Address: NCBOT, P.O. Box 2280, Raleigh, NC 27602

*An Occupational Therapy Practitioner is required by law to give written notice

of name, address or employment change within 10 days of such change.

PERSONAL INFORMATION

NC License #: _______________

Last

Name: ______________________ First: _____________________ Middle/Maiden: _____________

(Printed)

Address: ________________________________________________________________________

City: _______________________County: ___________________State: ________ Zip: ________

Home Phone: (________) ___________________ Cell Phone: (________) ___________________

Social Security# XXX-XX- _________ Email Address: ____________________________________

____________________________________________________

(Printed)

PREVIOUS NAME (if applicable)

EMPLOYMENT:

Place of Employment: _______________________________________ Phone: (_____) __________

Physical Address in NC: _____________________________________________________________

City: __________________________County: ___________________State: __NC___ Zip: ________

DOES THIS REFLECT:

EFFECTIVE DATE



Name Change?*

Yes

_________________



Address Change?

Yes

_________________



Employment Change?

Yes

_________________

If Yes, List Previous Information:

Name: ___________________________________________________________________________________________

Address: _________________________________________________________________________________________

: _______________________________________________________________________

Previous Employment

________________________________________________________________________________________

PRINT your new name as you want it to appear on your next renewal card

__________________________________________________________

_______________________

SIGNATURE

DATE

*Please attach a photocopy of proof of your name change, i.e.: marriage license, divorce papers, or court documents

relating to legal change of birth name. (A copy of driver license or social security card is not acceptable.) There is a

$15 charge for a new 8½” X 11” certificate and a $5 charge for a new wallet-sized renewal card. You may print out

license verification at

at no charge.

Rev 12/09

North Carolina Board Of Occupational Therapy

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