Nevada State Board of Physical Therapy Examiners
Nevada State Board of Physical Therapy Examiners
7570 Norman Rockwell Lane, Suite 230 ∙ Las Vegas, NV 89143
Phone (702) 876-5535 ∙ Facsimile (702) 876-2097
CHANGE OF
PRIMARY PROFESSIONAL ADDRESS FORM
Pursuant to NAC 640.061, each licensee shall file, in writing, his current residential address and primary professional address within 30 days after the change. In that regard, you may use this form to change your primary professional address with the Board. We will accept a completed form via mail or facsimile.
You will be mailed a post-card receipt as confirmation of the change.
PLEASE PRINT LEGIBLY and provide complete information
(if not currently working, check the box below)
LICENSEE NAME ______________________________________________________________
______________________________________________________________________________
(Business Name)
______________________________________________________________________________
(Address – cannot be P.O. Box)
______________________________________________________________________________
(City, State, Zip)
WORK PHONE ( ) ___________________ WORK FAX (_______) __________________
( I AM NOT CURRENTLY WORKING IN THE PHYSICAL THERAPY FIELD
SIGNATURE _______________________________________ DATE ___________________
NOTE: A professional change of address is necessary only when you change your primary professional address. This form is not to report any secondary practice locations. When working at a secondary location you must post a copy of your current license while you are present. Your original Board issued license must remain posted at your primary location at all times the facility is open. NAC 640.560
Posted 12/6/2011 rev. 05/11
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