State Board of Physical Therapy
Address Change Form

N.J.A.C. 13:45C-1.3(a)7 requires that all New Jersey licensees provide a timely notice of any change of address from that which appears on the licensee's most recent license renewal or application.

If your MAILING ADDRESS is not current, you will not receive your license renewal form or any other Board mailings. To ensure that you will receive all Board mailings you must immediately send the Board your current address information.

Be advised that your New Jersey licensing board/committee retains your: Home Address, Business Address and Mailing Address. One of these you determine to be your address of record. Your address of record is the address that will be printed on your renewed license certificate. Your name and this address may also be posted as part of the Online Licensee Directories at: http://www.state.nj.us/lps/ca/director.htm . As a matter of information, under the public disclosure law as it currently stands, any of your license addresses (address of record, home, business and mailing) must be provided if requested under the Open Public Records Act. If you do not indicate an address of record, your mailing address will be considered your address of record. An address of record may be a post office box address, only if another address with a street address is provided.

This change of address form may be completed and submitted electronically by clicking the "Submit the Form" button below to meet the address reporting requirement. This form is for address change reporting only.

RENEWAL APPLICATIONS ARE NOT FORWARDED
BY THE POSTAL SERVICE TO A FORWARDING ADDRESS.

 

 

(*Indicates required fields)

Last name*:
First name*:
Two-letter prefix code*:
License number*:
Date of birth*:	(Use MM-DD-YY format. The date of birth will be used for verification purposes only.)
Daytime telephone #:	(Use 555-555-5555 format. The telphone will be used in the event that questions arise concerning this change of address form.)
E-mail address:

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Old	mailing address
	business address
	home address

Street:
City:
State:
ZIP Code:
Country:	(if not U.S.A.)

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New mailing address
Is this your address of record? Yes No

Business or Practice Name (if applicable)*:
Street:
City:
State:
ZIP Code:
Country:	(if not U.S.A.)

Note: If your mailing address is a business or practice location, you must provide the business or practice name in order to ensure mail delivery.

New business address
Is this your address of record? Yes No

Business or Practice Name (if applicable)*:
Street:
City:
State:
ZIP Code:
Country:	(if not U.S.A.)

New home address
Is this your address of record? Yes No

Street:
City:
State:
ZIP Code:
Country:	(if not U.S.A.)

 

           

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If you have made a legal name change it is imperative that this legal name change be reported immediately to the State Board of Physical Therapy. You must mail the following items to the Board office c/o Professional Board Consumer Service Center, PO Box 45046, Newark, New Jersey 07101.

1. Your PRINTED former name,
2. Your PRINTED new name,
3. Your license number (be sure to include the two-letter prefix with your license number) AND
4. A copy of your marriage certificate, decree of divorce or court order.