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    Licensee Name Change

    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 complete the name change request form and submit one of the following:
    1. a certified marriage certificate specifying the name change following marriage;*
    2. a certified divorce or dissolution of marriage decree specifying the name change, or;*
    3. other certified court order specifying the name change.*
     

    *You may submit a notarized copy. Please note that the notarization must be the original inked notarization from the Notary and that the Board cannot accept copies of a previously notarized document or faxed or emailed versions of the submitted documentation. If a Notary is unable or unwilling to notarize your copy you will have to arrange to submit an original certified document.

    IF YOU WISH TO OBTAIN A NEW LICENSE CARD OR WALL CERTIFICATE DUE TO YOUR NAME CHANGE, PLEASE COMPLETE THE SECOND PAGE OF THE NAME CHANGE REQUEST FORM AND INCLUDE FEE PAYMENT TO PAY FOR THE NEW CARD/CERTIFICATE.

    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. 

    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.

    Send documentation to the Board at: Minnesota Board of Physical Therapy, 2829 University Ave SE, Suite 420, Minneapolis, MN 55414

    If you are requesting a duplicate license for a name change and wish to obtain an updated copy of your license please follow the process outlined below.

    Duplicate License

    • You must complete all sections of the form by printing or typing
    • The form must be notarized
    • The fee for a new wall certificate (8 ½” x11”) is $20.00 and a new annual license card is $20.00
    • Duplicate renewal cards or wall certificates will not be generated after a name or address change without this request form and the fees

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