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.
Step 1: To submit a change request, a reinstatemtent or reactivation application, click on the fillable form below. Complete all fields before printing. The request form must then be signed and uploaded to the online application portal below.
Name Change Request
Step 2: Upload the completed request form and all supporting documents using the links below.
Name Change Request Online Application
Change of Address Request Online Application
Email/Phone Change Request Online Application