REQUEST FOR CHANGE OF NAME AND/OR ADDRESS …
(4/2016)
MAILING ADDRESS:
PO BOX 2649 Harrisburg, PA 17105-2649
STATE BOARD OF OCCUPATIONAL THERAPY st-occupational@ (717) 783-1389 dos.therapy
COURIER ADDRESS:
2601 North Third Street Harrisburg, PA 17110
REQUEST FOR CHANGE OF NAME AND/OR ADDRESS
FEE: To obtain a duplicate license reflecting the change of name and/or address, you must return this application and a $5 fee (check or money order payable to the "Commonwealth of Pennsylvania.")
To obtain a duplicate of your temporary license, the fee is $15.00. Without the fee, the change will be processed but no duplicate will be issued. A processing fee of $20 will be charged for any check/money order returned unpaid by your bank regardless
of the reason for non-payment.
LICENSEE'S Last NAME: LICENSE #: SOCIAL SECURITY #:
CHANGE OF NAME
LICENSEE INFORMATION
PLEASE PRINT OR TYPE
First
TELEPHONE NUMBER: EMAIL ADDRESS:
Middle
DATE OF BIRTH:
You must submit a copy of a legal document verifying the name as it is currently listed in the Board's records and also provide the new name. The following are acceptable name change verification documents:
(1) Marriage certificate; (2) Divorce decree which indicates the retaking of your maiden name; (3) Other "legal" document indicating the retaking of a maiden name; (4) For a "legal" name change, a copy of the court document must be provided
Last NEW NAME:
CHANGE OF ADDRESS
First
Middle Initial
OLD ADDRESS:
City
NEW ADDRESS:
City
CHANGE OF EMAIL
OLD EMAIL ADDRESS: NEW EMAIL ADDRESS:
State
State
Zip Code
Zip Code
................
................
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