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

Preview

Affirm pay and 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 : 08/07/2020
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 :
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