MARYLAND STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE
Request for Rosters, Labels, and/or Disks
Instructions:
- Complete Form
- Make checks or money orders payable to
: Maryland Board of Occupational Therapy
Practice (MBOT)
- Return Request Form with payment
to: Spring
Grove Hospital Center, 55 Wade Avenue, Baltimore, MD 21228
(Please allow 4 weeks for your completed
request to be delivered.)
|
Status (Circle Status Option(s)
Desired) |
# of Licensees |
Price
List (Circle Price for Desired Format) |
Check
Selection Desired |
| |
|
Labels |
Rosters |
|
|
| |
Approximate Count |
Avery gummed
labels - 1 per licensee |
Word 97 format
- sent via email |
ASCII text file
- sent via email |
Excel 97 file - sent via email |
Alpha Order |
Zip Code Order |
|
Occupational Therapists:
Maryland Residents Only |
|
|
|
|
|
|
|
| 1. Active Licenses Only |
2,095 |
$ 85 |
$ 55 |
$ 55 |
$ 55 |
|
|
| |
|
|
|
|
|
|
|
|
Occupational Therapists:
All Residents (In State + Out of State) |
|
|
|
|
|
|
|
| 2. Active Licenses Only |
2,448 |
$95 |
$55 |
$55 |
$55 |
|
|
| |
|
|
|
|
|
|
|
|
Occupational Therapy Assistants:
Maryland Residents Only |
|
|
|
|
|
|
|
| 3. Active Licenses Only |
392 |
$65 |
$55 |
$55 |
$ 55 |
|
|
| |
|
|
|
|
|
|
|
|
Occupational Therapy Assistants:
All Residents (In State + Out of State) |
|
|
|
|
|
|
|
| 4. Active Licenses Only |
529 |
$65 |
$55 |
$ 55 |
$ 55 |
|
|
Name:
___________________________________________________
Phone: (_____) ___________________ Total Amount Enclosed: ________________
Address: ___________________________________________________
City: __________________________ State: _______ Zip Code: ______________
E-mail Address: __________________________________________________________________________________
Rev. 7/2010
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