Request for Certified PT Information Update

Please complete all fields below ...

fields marked with a "*" are required
*Certification Number (will be used to confirm ID):
*Name:
Designation Initials (may be truncated for space):
NAIOMT Certification Level:	None selected Level III CMPT Level IV COMT
Name of workplace:
Address:
Address line 2:
City:
State:
ZIP:
Country:
Email:
Phone:
Fax:
I agree that NAIOMT may release only the information designated above. I realize this information may be released to the general public by means of the NAIOMT Certified PT webpage:	yes no
Other comments: