Payment made on_________ by No ________ For office use only: Occupational Therapy Licensing Board , Phone: 971-673-0198 FAX: 971-673-0226 $215 The OT Application fee is currently the 2 year fee of $175 + $40 (fingerprint/background check fee) = , good through May 31, 2020. $140. If you do not need your license until March 1, 2019, pay the 1 year fee: $100 + $40 (fingerprint/background check fee) = OCCUPATIONAL THERAPIST LICENSE APPLICATION Return signed, complete form with or money order payable to the OT Licensing Board”. “Oregon Have state verification(s) sent to Oregon from any state where you have ever been licensed and worked. Send OT school transcripts IF you just took NBCOT exam; not required if entering by endorsement from another state. Pass the New Oregon Law/Ethics exam required for all new applicants. If you are a new graduate, pay to have NBCOT scores transferred to Oregon. Have digital fingerprints taken at any Field Print location. Provide Fieldprint with OT Board agency code FPOccuTheraLicBd. License Expires May 31, 2020 PERSONAL INFORMATION 1. FIRST NAME MI Other names used: LAST NAME GENDER: 2. PREFERRED MAIL ADDRESS Note: Correspondence will be mailed to BIRTH DATE SOCIAL SECURITY NO. HOME preferred address. See Privacy Notification WORK 3. HOME ADDRESS (MAILING: STREET OR BOX) PHONE 4. CITY Home ZIP 5. E-MAIL ADDRESS (We save $ by use of e-mail; we do not give it out unless required by law; please keep it updated) FUTURE OREGON EMPLOYMENT (LEAVE BLANK IF UNKNOWN) 6. FACILITY POSITION Temp Co? 7. WK. ADDRESS (MAILING: STREET OR BOX) WK. 8. WK. ZIP EDUCATION 9. COLLEGE / UNIVERSITY WHERE OT DEGREE RECEIVED CITY / STATE 10. DEGREE AREA OF STUDY GRADUATION DATE (month/year) LICENSURE & HISTORY INFORMATION 11. Have you passed the National Certification Exam? Indicate # ___________ Yes No If not, what is your scheduled date to take exam: _______________________
Occupational Therapy Licensing Board , Phone: 971-673-0198 FAX: 971-673-0226 The OT Application fee is currently the 2 year fee of $175 + $40 (fingerprint/background check fee) = $215 , good through May 31, 2020. If you do not need your license until March 1, 2019, pay the 1 year fee: $100 + $40 (fingerprint/background check fee) = $140. For office use only: Payment made on_________ by No ________ OCCUPATIONAL THERAPIST LICENSE APPLICATION Return signed, complete form with or money order payable to the “Oregon OT Licensing Board”. Have state verification(s) sent to Oregon from any state where you have ever been licensed and worked. Send OT school transcripts IF you just took NBCOT exam; not required if entering by endorsement from another state. Pass the New Oregon Law/Ethics exam required for all new applicants. If you are a new graduate, pay to have NBCOT scores transferred to Oregon. Have digital fingerprints taken at any Field Print location. Provide Fieldprint with OT Board agency code FPOccuTheraLicBd. License Expires May 31, 2020 PERSONAL INFORMATION 1. FIRST NAME GENDER: MI LAST NAME Other names used: 2. PREFERRED MAIL ADDRESS HOME WORK Note: Correspondence will be mailed to preferred address. SOCIAL SECURITY NO. See Privacy Notification BIRTH DATE 3. HOME ADDRESS (MAILING: STREET OR BOX) PHONE 4. CITY Home ZIP 5. E-MAIL ADDRESS (We save $ by use of e-mail; we do not give it out unless required by law; please keep it updated) FUTURE OREGON EMPLOYMENT (LEAVE BLANK IF UNKNOWN) 6. FACILITY Temp Co? POSITION 7. WK. ADDRESS (MAILING: STREET OR BOX) WK. 8. WK. ZIP EDUCATION 9. COLLEGE / UNIVERSITY WHERE OT DEGREE RECEIVED CITY / STATE 10. DEGREE AREA OF STUDY GRADUATION DATE (month/year) LICENSURE & HISTORY INFORMATION 11. Have you passed the National Certification Exam? Indicate # ___________ Yes No If not, what is your scheduled date to take exam: _______________________
OT%20License%20Application%202018.docx