ࡱ> =@<' xbjbj 8$TdTd gCCCWWWW4W:444$E v@C4"444@9Unnn4"8Cn4nn+n 0V"nk0nq!xq!nnq!C44n44444@@T4444444q!444444444 : NORTH DAKOTA STATE BOARD OF OCCUPATIONAL THERAPY PRACTICE PO BOX 4005 BISMARCK, ND 58502-4005 701-250-0847 Fax 701-224-9824  HYPERLINK "mailto:ndotboard@aptnd.com" ndotboard@aptnd.com  HYPERLINK "http://www.ndotboard.com/" www.ndotboard.com List/Labels Request Form (This form is not required if all information is included in a written request!) There is no charge for a list sent by email. For labels or a paper list, there is a charge of $0.25 per page. Please send check or money order made payable to NDBOTP. You will need to contact the Board office to find out the exact fee for labels. Person requesting list __________________________________________________________________ Organization or business name ___________________________________________________________ Address ____________________________________________________________________________ City __________________________________ State__________________ Zip Code _______________ Phone ________________________________ Email _________________________________________ I request the following (Please attach a sheet explaining any requested fields or special instructions): Purpose of the list (Please mark one): O Continuing Education O Employment Recruiting O Research O Other ______________ Are there any specific fields you request? ___________________________________________________________ According to NDCC 44-04-18.1 and NDCC 44-04-18.21, home address, phone number, and email are given out at the discretion of the Board. Social Security Number and birth month/day are closed records and cannot be given out. License Level (Mark as many as necessary): O Occupational Therapists O Occupational Therapy Assistants List/label order (Mark one): O Alphabetical O License Number O Zip Code O No order O Other _________ Format (Please mark one): O Email O Paper List O Mailing Labels (For lists by email, the list is sent in pipe-delimited format, as that is recommended by our tech people. However, it should open in Excel. Please note if you need instructions how to convert it the list to Excel and it will be included with your list.) List/labels sent to (Mark one): O Email address listed above O Address listed above O Address listed below Name _________________________________________ Business _____________________________ Address ____________________________________________________________________________ City __________________________________ State__________________ Zip Code _______________ If you request an email list, you may submit your request to the Board office by email,  HYPERLINK "mailto:ndotboard@aptnd.com" ndotboard@aptnd.com. If you request a list or labels, please mail it to the above mailing address. Contact the Board office, if you have any questions.  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