NBCOT CERTIFICATE ORDER FORM Send a copy of this

NBCOT CERTIFICATE ORDER FORM Send a copy of this form and payment to: NBCOT Attn: Certificate Order PO Box 64971 Baltimore, MD 21264-4971 If paying by credit card you may fax this form to: 301-869-8492. NBCOT suggests you make a photocopy of this request for your files. _______________________________________ _______________________________________ ♦ Certification Number and Level OCCUPATIONAL THERAPIST REGISTERED OTR ® ♦Name (Please Print) or CERTIFIED OCCUPATIONAL THERAPY ASSISTANT COTA ® _______________________________________ (_________)______________________________ ♦Home Address _______________________________________ ♦Daytime Phone Number (_________)______________________________ ♦City, State, Zip _______________________________________ ♦ Home Phone Number _______________________________________ ♦Social Security Number ♦Date of Birth ♦Method of Payment ($20.00 United States Dollars) – Please check one: ♦Check __________ ♦Money Order __________ ♦Credit Card __________ ♦ Certificate Order Date ________________________ Visa/MasterCard: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Credit Card Expiration Date: ______ ______/ ______ ______ (month) (year) Cardholder Signature: ____________________________________________________________________ (Signature Required for Charge Card Requests)