Licensee Address List Application

Instructions

Instructions

Please disable pop up blockers before proceeding further. Once the request has been submitted, you will see a success message and the CSV file will be downloaded

Requestor Information

Preview

Affirm pay and submit

I affirm that all information provided herein is true and correct and I recognize that providing false information may result in disciplinary action

Date : 05/24/2019
E-Signature :

(Board of Physical Therapy charge will appear as "ALABAMA BOARD OF PHYSICAL THERAPY" and convenience fee will appear as "iGov ePay LLC" on your statement.)

Amount Due :
Transaction Fee :
Total :
Person's Name on Card:
Select Debit or Credit :
Card Type :
Card # :
* Expiration Date :
Security Code :
(Board of Respiratory charge will appear as "ALA ST BOARD OF Respiratory" and convenience fee will appear as "iGov ePay LLC" on your statement.)
Please note that after you click the Submit button, you cannot make changes to your application.

Mailing Address: 100 North Union Street, Suite 724, Montgomery, AL 36130-5040