Nevada State Board of Physical Therapy Examiners
Nevada Physical Therapy Board
7570 Norman Rockwell Lane, Suite 230 ∙ Las Vegas, NV 89143
Phone (702) 876-5535 ∙ Facsimile (702) 876-2097
Pursuant to NAC 640.055, a licensee who has lost his license or is otherwise not in possession of his license may request, in writing, from the Board a duplicate license. In that regard, you may use this form to request a duplicate license.
Please complete this form and mail it to the Board office with a copy of your driver’s license and a fee of $25 made payable to the Nevada State Board of Physical Therapy.
PLEASE PRINT LEGIBLY
NAME: __________________________________________________________________
LICENSE # _______________________________________________________________
( Requesting Current License ( Requesting Permanent License ( Requesting Both
(the $25 fee covers one or both licenses)
SIGNATURE: __________________________________________________
DATE: __________________
BOARD OFFICE USE ONLY
( Current License
( Permanent License
-----------------------
REQUEST FOR DUPLICATE LICENSE
Please Type or Print Legibly
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