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IMPORTANT INFORMATION REGARDING NAME CHANGES

If you are a Physical Therapist or Physical Therapist Assistant, and you have undergone a legal name change via marriage, divorce or otherwise, please be advised that in order for the Board to change the name in which your PT or PTA license is issued, you are REQUIRED to submit one of the following:
  1. completed name change request form 
  2. a certified marriage certificate specifying the name change following marriage;*
  3. a certified divorce or dissolution of marriage decree specifying the name change, or;*
  4. other certified court order specifying the name change.*

Please do not submit foreign marriage certificates that do not reflect your name change following marriage, as the Board is unable to accept them for purposes of changing your name on your license.

*You may submit a notarized copy

How to obtain a notarized document:

  1. Make a photocopy of the document (marriage certificate, etc).
  2. Take the photocopy along with the original document to a Notary.
  3. The Notary will look at the original document and the photocopy.
  4. The Notary will sign/stamp/seal the photocopy and write a statement to the effect that they have viewed the original and this is an exact copy. Some Notaries will attach a paper (with a similar statement, signature/stamp/seal) to the copy. 

Name Change Request Form

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