Change Requests

​It is the responsibility of the licensee to report any change of mailing address, name or email/phone to the Board within 30 days of the change. The change request form must be signed; electronic signatures are not accepted. Submission of a request with an electronic signature will result in your request being incomplete. Incomplete applications will not be processed until the request form is received with a physical signature.​

Step 1: ​To submit a change request click on the fillable form below. Complete all fields before printing.

Step 2: ​Upload th​e completed request form and all supporting documents using the links below.