MARYLAND STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE

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					            MARYLAND STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE
                                                               Spring Grove Hospital Center
                                                                     55 Wade Avenue
                                                                Baltimore, Maryland 21228
                                                                   Phone (410) 402-8560
                                                            http://dhmh.maryland.gov/botp

                                                     REQUEST FOR ROSTERS AND LABELS
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.)


                                                             # of                                                                     Check
       Status: Circle Status Option(s)                    Licensees               Price List (Circle Price for Desired               Selection
                  Desired                                 ( as of 7/12/10)                      Format)                               Desired
                                                                                     Labels                 Rosters
                                                                                  Avery       Word 97     ASCII text    Excel 97
                                                         Approximate             gummed       format –    file - sent    file –    Alpha   Zip Code
                                                            Count               labels – 1     sent via   via email     sent via   Order    Order
                                                                               per licensee     email                    email
     Occupational Therapists: Maryland
              Residents Only
     1. Active Licensees 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 License 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: ___________

Mailing Address: _________________________________ City: __________________ State: _____ Zip: _______________

E-mail Address: _________________________________________________________________




L:\OT\Forms\Labelsrev10.doc                                                                                                            Rev. 7/2010

				
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