Certificate of Good Standing - PUBLIC - OTBNZ | The Occupational Therapy Board of New Zealand (OTBNZ) is a regulatory authority for occupational therapy practitioners.

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Certificate of Good Standing - PUBLIC

Use this form to request the OTBNZ generate and send a Certificate of Good Standing to your nominated individual or organisation

SECTION A: Personal Details

First Name *

Surname *

Middle Name(s)

Former First Name (if applicable)

Former Surname (if applicable)

Contact email address *

Date of Birth *

Registration Number

SECTION B: Individual or Organization to receive Certificate

Certificate to be sent how?

Post

Name of Individual or Organization

Contact Person

Email Address

Postal Address

Address look-up

Number and Street or PO Box

Suburb / RD No.

Country

Town or City

Postcode

Please read and make sure you understand these statements before signing:

SECTION C: Declaration

Declaration:
• I am the registrant named in this document.
• I authorise that the Verification of Registration certificate which provides details of my registration, any conditions on my registration and any disciplinary proceedings underway or contemplated to be released to the individual or organisation named on this form.

Signature

Date

Fee