MARYLAND STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE

Request for Rosters, Labels, and/or Disks

Instructions:

  1. Complete Form
  2. Make checks or money orders payable to :      Maryland Board of Occupational Therapy Practice (MBOT)
  3. 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 diskette ASCII text file sent via email Alpha Order Zip Code Order

Occupational Therapists:  Maryland Residents Only

                     
1.  Active Licenses Only

1,582

 $ 85 $ 55 $ 55 $ 55                  
               

Occupational Therapists:   All Residents  (In State + Out of State)

                     
2.  Active Licenses Only

1,913

 $95 $55 $55 $55      
               

Occupational Therapy Assistants:  Maryland Residents Only

                      
3.  Active Licenses Only 328 $65 $55 $55 $ 55      
               

Occupational Therapy Assistants:  All Residents (In State + Out of State)

                     
4.  Active Licenses Only 433 $65 $55 $ 55 $ 55      

*Note:  When requesting information on disk, a disk must be supplied.  Final information will be provided in ASCII text format.

Name:  _____________________________________________________    Phone:  (_____) _____________________        Total Amount Enclosed:  ________________

Address:  ___________________________________________________    City:  _____________________________    State:  _______    Zip Code:  ______________

E-mail Address:  __________________________________________________________________________________

   Rev.  6/2001