Name Change

Fields in bold are required.
There is a $20.00 fee for a wall certificate with a name change.

Yes, I require an updated wall certificate at a cost of $20.00.
No, I do not require an updated wall certificate.

If you require a wall certificate, you will be charged at the end of the name change process. Please have a Visa or Mastercard account for the charge. An updated wall certificate will be mailed to you once the payment has been approved.

Make sure to have the following information before you begin the name change process:
1. Your first and last name;
2. Your social security number;
3. Your PT/PTA license number;
4. A current Visa or MasterCard account;
5. The expiration date of the Visa or MasterCard account.

All information entered will be encrypted, so your data will be transmitted safely and securely.

Please call the board if you have any questions about your name change.

    
Choosing exit will take you out of the name change process.