Licensee Address List Application

Instructions

Instructions

Please disable pop up blockers before proceeding further. Once the request has been submitted, you will see a success message and the CSV file will be downloaded

Requestor Information

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Submit

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

Date : 11/21/2024
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.

Mailing Address: 100 North Union Street, Suite 724, Montgomery, AL 36130-5040. Privacy Policy