Get Address Change Form - State Of Oregon - Oregon

The Address Change Form for the State of Oregon allows licensed physical therapists to update their address and contact information. It is important to maintain accurate records with the Oregon Physical Therapist Licensing Board, and this guide will help you navigate the form easily and effectively.

Follow the steps to fill out the Address Change Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name in the designated fields: 'Last', 'First', and 'Middle'. Ensure your name matches the one on your professional license.
3. Input your license number in the corresponding field. This is crucial for identifying your record with the licensing board.
4. Provide the effective date of change. This date indicates when the address change is applicable.
5. Enter your new mailing address. Fill in 'Address Line One' and 'Address Line Two' if necessary, followed by your city, state, and zip code. Include a private email address for Board use only, as well as a public email address if desired.
6. Complete your home address section by providing your street address, city, state, and zip code. Also, include your phone number and cell number with area codes.
7. Fill out your work address details, including employer name, street address or P.O. Box, city, state, and zip code. Don't forget to add your work phone number with area code.
8. Review all the entered information for accuracy. Ensure that all fields are filled out correctly before signing.
9. Sign and date the form at the bottom. Your signature confirms that the information provided is accurate.
10. After completing the form, you can save your changes, download, print, or share the form as needed. Be sure to submit it to the Oregon Physical Therapist Licensing Board via mail, fax, or email.

Take the next step and complete your Address Change Form online today!