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

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REQUEST FOR DUPLICATE LICENSE

Please Type or Print Legibly

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