National Board for Certification in Occupational Therapy, Inc. (NBCOT®)
01/03/08
NBCOT® certificants who have submitted their examination application and wish to have a confirmation notice sent to a regulatory entity, employer, or themselves should complete this request form. The confirmation notice includes: 1. Confirmation that the candidate’s examination application and fees have been processed 2. Confirmation that the candidate’s official final transcript or NBCOT Academic Credential Verification Form (ACVF) is in order 3. Confirmation that the candidate is approved to schedule his/her test date with Prometric Test Center 4. The candidate’s examination history—a listing of the candidate’s examination dates, 1997—present List the jurisdiction(s) to which a confirmation notice should be sent. Please Note—The following states do NOT accept confirmation notices: Colorado, Connecticut, Hawaii, Iowa, Michigan, Mississippi, North Carolina, South Carolina and Utah. 1. Postal Code: 2. 3. List the employer(s) to which a confirmation notice should be sent. Attn: Company Name: Address : City: State: Attn: Company Name: Address : City: State: Postal Code/Zip:
Checks and money orders should be made payable to “NBCOT,” and must be drawn on a U.S. bank.
Fee $40 per notice
Please Note: When a confirmation notice is requested for a third party, the candidate will receive a copy at no charge. Name: Street Address: City: State/Province: Country: Daytim e Phone: Social Security or Student ID #: School Code: Examination Level: OTR® COTA®
Choose one: Please send a Confirmation of Examination Registration and Eligibility to Examine Notice to each of the entities indicated. I have included the $40 fee for EACH notice requested. I understand that I will receive a copy of the notice at no extra charge. I am not requesting a Confirmation of Examination Registration and Eligibility to Examine Notice for a third party at this tim e, but would like to have this notice sent to me, at the address listed above. I have included the $40 fee. Please sign: I hereby authorize NBCOT to send confirmation notices as indicated on this form. Signature: Date:
Postal Code/Zip:
number of notices: _____ x fee per notice: $ 40
Choose a Payment Method: Credit Card Number: Expiration Date (mm/yy): Credit Card Holder: Card Holder’s Billing Address (required): Signature of Cardholder: Personal Check —
= total payment: $ _____
Visa — MasterCard
Money Order —
Mail form and payment to:
NBCOT, Inc. P.O. Box 64971 Baltimore, MD 21264
I authorize the amount indicated above to be charged to my credit card.
Questions? Contact NBCOT: (phone) 301-990-7979
(e-mail) onlineexamapp@nbcot.org
(website) www.nbcot.org