Licensee Address List Application



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Requestor Information



I affirm that all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action

Date : 06/25/2022
E-Signature :

(Board of Physical Therapy charge, including a convenience fee, will appear on your statement with a description including IGOVSOL*.)

Amount Due :
Transaction Fee :
Total :
Person's Name on Card:
Select Debit or Credit :
Card Type :
Card # :
* Expiration Date :
Security Code :
Billing Zip Code:
Please note that after you click the Submit button, you cannot make changes to your application.

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