NEVADA PHYSICAL THERAPY BOARD 7570 NORMAN ROCKWELL LANE SUITE

1 TITULO EL FRIAJE (NEVADAS) EN AREQUIPA 2 DESCRIPCIÓN
APPLICATION FOR COUNTY LIQUOR LICENSE STATE OF NEVADA COUNTY
BRIAN SANDOVAL GOVERNOR STATE OF NEVADA BRUCE H BRESLOW

C HORUS OF THE COMSTOCK CARSON CITY NEVADA A
DEPARTMENT OF BUSINESS AND INDUSTRY NEVADA DIVISION OF INSURANCE
DESDE ALFANEVADA SE ESTÁ LLEVANDO A CABO UN PROYECTO

Nevada State Board of Physical Therapy Examiners

Nevada Physical Therapy Board

7570 Norman Rockwell Lane, Suite 230 ∙ Las Vegas, NV 89143

Phone (702) 876-5535 ∙ Facsimile (702) 876-2097

REQUEST FOR DUPLICATE LICENSE

Please Type or Print Legibly

Pursuant to NAC 640.055, a licensee who has lost his license or is otherwise not in possession of his license may request, in writing, from the Board a duplicate license. In that regard, you may use this form to request a duplicate license.

Please complete this form and mail it to the Board office with a copy of your driver’s license and a fee of $25 made payable to the Nevada State Board of Physical Therapy.

PLEASE PRINT LEGIBLY

NAME: __________________________________________________________________

LICENSE # _______________________________________________________________

 Requesting Current License  Requesting Permanent License  Requesting Both

(the $25 fee covers one or both licenses)

SIGNATURE: __________________________________________________

DATE: __________________

NEVADA PHYSICAL THERAPY BOARD 7570 NORMAN ROCKWELL LANE SUITE

BOARD OFFICE USE ONLY

 Current License

 Permanent License

DIGITAL ARCHIVE IS ASCII ASCII FILENAME NEVADAARCHIVE 250 BYTES
ID 020605 SOLICITUD CURSO DE ESQUÍ EN SIERRA NEVADA
JUSTICE COURT LAS VEGAS TOWNSHIP CLARK COUNTY NEVADA CASE

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