It is the responsibility of the licensee to report any change of name to the Board within 30 days after the change. The completed Name Change Form and copies of official proof of the name change must be submitted to the Board. Please see the following items that can be submitted as official proof:

• Marriage Certificate
• Divorce Decree
• Court Order Issued for Name Change

A fee of $5.00 is required for issuance of a replacement license with a new name and the licensee must submit payment via credit card using the link below. Once paid please upload a copy of your receipt and check the box below.

Please complete the fillable Name Change Request Form below if you haven't already done so. Once completed, scan and upload a copy of the form along with copies of your official proof documents.

Name Change Form