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STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE
SPRING GROVE HOSPITAL CENTER
BLAND BRYANT BUILDING - 4TH FLOOR
55 WADE AVENUE
BALTIMORE, MD 21228
410-402-8560
VERIFICATION OF LICENSURE FORM
PART I: TO BE COMPLETED BY APPLICANT 1.
Name:
_______________________________________________________________________________________________________ 2.
Address:
_____________________________________________________________________________________________________ 3:
City: ______________________________________________________ 4.
State: __________________ 5. Zip: _______________ 6.
Home Phone: (_____) ________________________________
7. Work Phone: (_____) ___________________________________ 8.
State or foreign country in which you are/were licensed:
__________________________________________________ None ¨
Make a copy of this form for each state or foreign country in which you are or
ever have been licensed. PART II: TO BE COMPLETED
OR RETURNED WITH EQUIVALENT DOCUMENTATION BY STATE OR FOREIGN COUNTRY The
Occupational Therapist or Occupational Therapy Assistant listed above has
applied for licensure in the State of Maryland. Please provide the
following information.
| 9. Occupational Therapist |
Yes ¨ |
No ¨ |
10. Occupational Therapist
Assistant |
Yes ¨ |
No ¨ |
| 11. License Number
___________________ |
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12. Status:
_________________________ |
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| 13. Date Issued:
_____________________ |
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14. Expiration Date:
_________________ |
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| 15. Did the licensee obtain
a temporary license only: |
Yes ¨ |
No ¨ |
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| 16. If yes, can the
temporary license be verified via this form? |
Yes ¨ |
No ¨ |
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| 17. Has this license ever
been surrendered, suspended, or revoked? |
Yes ¨ |
No ¨ |
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| 18. If yes, has the license
been reinstated: |
Yes ¨ |
No ¨ |
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| 19. The Board
of ______________________________________________ of the State of
____________________________________ certifies that the above information
is correct. |
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20. Signature
________________________________________________________ |
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Title
____________________________________________________________ |
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(SEAL)
Date ____________________________________________________________ |
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Agency Address
___________________________________________________
_________________________________________________________________
_________________________________________________________________ |
TDD FOR DISABLED
MARYLAND RELAY SERVICE
1-800-735-2258 PLEASE RETURN DIRECTLY TO
THE MD BOARD OF OT
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