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National Board for Certification in Occupational Therapy, Inc.
ID 28 rev100814
Name Change Request Form
NBCOT® candidates and certificants who have had a name change should use this form. If only your address has changed, you do not need to complete
this form. Instead, you can update your address by logging into your MyNBCOT portal at www.nbcot.org. Thank you.
NBCOT requires legal documentation in order to process a name
change. Only copied documents should be submitted. If you submit an
original to NBCOT, please include a self-addressed stamped envelope
so that we may return it to you.
If your name has changed please submit along with this form a copy of
one of the following current valid government-issued IDs that records
your current legal name: driver’s license, state-issued ID, passport,
military ID.
Some examples of unacceptable IDs are: social security card, library
card, student ID.
Fees:
The amount due (if applicable) will vary according to
individual circumstances.
Certificants (those who have an NBCOT Certificate)
Name Change without new Certificate and Wallet ID
Card or submitted along with Certification Renewal
Application
No charge
Name Change with new Certificate and Wallet ID Card $30.00
Wallet ID cards not available without ordering a certificate.
Upon receiving your completed request form [below] and appropriate
documentation, your certification record will be updated. You will be
notified by email that your name change has been updated (provided a
current email address is on file). Please allow 10-15 business days for
processing.
Candidates (those who have not yet taken the Certification Exam)
New Name Information
Select Status
First Name:
Certificants (if you have an NBCOT Certificate):
Middle Name:
If the ATT Letter has not been issued yet
No charge
If the ATT Letter has been issued
$75.00
Last Name:
I am not requesting a new Certificate and Wallet ID Card
at this time (no charge)
Prior Last Name:
Please send me a new Certificate and Wallet ID Card ($30.00)
Date of Birth:
Candidates (if you have not taken the NBCOT Certification Exam):
NBCOT Certification Number (if applicable):
My ATT Letter has not been issued yet (no charge)
Has your contact information also changed?
My ATT Letter has been issued ($75.00)
Street Address:
City:
State/Province:
Country:
Postal Code:
Phone (day):
Email:
Send your form and documentation:
NBCOT, Inc.
12 S. Summit Avenue, Suite 100
Gaithersburg, MD 20877
Email: [email protected]
Fax: 301-869-8492
(No check or money order payments accepted by fax or email.)
Questions? Contact NBCOT: (phone) 301-990-7979
Choose a Payment Method:
Checks/money orders should be
made payable to “NBCOT,” and
must be drawn on a U.S. bank.
Personal Check
Money Order
Visa
MasterCard
Credit Card Number:
Expiration Date (mm/yy):
3-Digit CVV Code:
Credit Card Holder:
Card Holder’s Billing Address (required):
Signature of Cardholder:
I authorize the amount indicated to be charged to my credit card.
(e-mail) [email protected]
(website) www.nbcot.org