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    Request for Rosters, Labels, and/or Disks


    1. Complete Form
    2. Make checks or money orders payable to : Maryland Board of Occupational Therapy Practice (MBOT)
    3. Return Request Form with payment to:      Spring Grove Hospital Center, 55 Wade Avenue, Baltimore, MD  21228

        (Please allow 4 weeks for your completed request to be delivered.)

    Status (Circle Status Option(s) Desired)

    # of Licensees

    Price List (Circle Price for Desired Format) Check Selection Desired


    Labels Rosters    

    Approximate Count

    Avery gummed labels - 1 per licensee Word 97 format - sent via email ASCII text file - sent via email Excel 97 file - sent via email Alpha Order Zip Code Order

    Occupational Therapists:  Maryland Residents Only

    1.  Active Licenses Only


    $ 85 $ 55 $ 55 $ 55                  

    Occupational Therapists:   All Residents  (In State + Out of State)

    2.  Active Licenses Only


    $95 $55 $55 $55      

    Occupational Therapy Assistants:  Maryland Residents Only

    3.  Active Licenses Only 392 $65 $55 $55 $ 55      

    Occupational Therapy Assistants:  All Residents (In State + Out of State)

    4.  Active Licenses Only 529 $65 $55 $ 55 $ 55      

    Name:  ___________________________________________________    Phone:  (_____) ___________________     Total Amount Enclosed:  ________________

    Address:  ___________________________________________________    City:  __________________________    State:  _______    Zip Code:  ______________

    E-mail Address:  __________________________________________________________________________________

       Rev.  7/2010

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