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Name/Address Changes
PT/PTA | Name/Address Changes
Name and Address Changes or (Personal Data Information Changes) Download "Name/Address Change Notification Form".
If you have had a name change during our renewal time October 1st through December 31st of the current year, and it is the year to renew your License, do the following:
Along with your renewal certificate (bottom part of your License), you must send in a notarized copy of the name change document, and your renewal fee. There is no charge at renewal time to have your name changed on your license. However, if you wish to have a new wall certificate also, you must include the $15.00 fee with your renewal fee, and request the wall certificate. Wall certificates will not be mailed until a later date-- possibly within three months later.
If you have had a name change any other time of the year:
You are required to send in the notarized copy of the document and $5.00 fee (check - no cash). If you are requesting a new wall certificate also, send the $15.00 fee for a total of $20.00. Within our 10 business day turn-around time, a new license will be sent to you, reflecting your name change. Wall certificates will not be mailed out until a later date--possibly within three months later.
How to get a document notarized:
Take your original document and a photocopy and have the notary notarize the copy. Send us the copy that the notary actually writes on - otherwise, it will be returned to you. You may have to provide ID to the notary.
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Address changes:You are required to send us typewritten address changes in writing - either by regular mail, fax, or e-mail. Please include the county as well, and phone # changes, including cell phone# and e-mail address, if you have one.
Work location changes:Send changes in writing, following the above directions. If you work in more than one place, give us that information, stating which one is your primary work location. Include the facility name, physical address (with the county), phone and fax numbers, and date of employment.
PTA's- include the name of your supervising PT and their PT #.
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