
NBRC CREDENTIAL VERIFICATION FORM
OHIO RESPIRATORY CARE BOARD
77 S. High Street, 16th Floor
Columbus, Ohio 43215-6108
614.752.9218
www.state.oh.us/rsp
TO APPLICANT:
The National Board for Respiratory Care, Inc. (NBRC) requires a fee to verify professional credentials.
Please complete Section 1 below and submit it, along with the required fee to:
NBRC Executive Office
18000 W. 105
th
Street
Olathe, KS 66061-7543
FEES (Based on active or inactive NBRC membership):
$5 fee for active members
$20 fee for inactive members
SECTION 1:
_____ I am applying for state licensure in (STATE NAME __________________), and I am requesting
the NBRC to verify my credential(s) directly to the (STATE AGENCY
______________________________).
I hold the following NBRC credentials:
____ RRT ____ CPFT ____ CRT-NPS
____ CRT ____ RPFT ____ RRT-NPS
PRINT NAME UNDER WHICH YOU WERE CREDENTIALED:
_______________________________________________________________
Last First Middle Initial Former Name
COMPLETE THE INFORMATION BELOW:
_______ - _______ - ________
Social Security Number
_______________________________________________________________
Last First Middle Initial Former Name
_______________________________________________________________
Street /Apt. #
_______________________________________________________________
City State Zip Code
_______________________________________________________________
Business Phone Home Phone
_______________________________________________________________
Signature Date
RCB 020 (4/07) This form supersedes all previous editions