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Please note that an application fee only extends an initial license to the next renewal date. Initial licenses do vary in duration. It is the responsibility of all licensees to renew their license before expiration. Failure to renew shall result in automatic forfeiture or suspension of the license by statute. Licenses which have forfeited are not automatically entitled to renew.

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Name Change Request

To have your legal name change updated on your licensure complete this webform and upload the legal document indicating the name change.

If you need a new card reflecting the change the Replacement card order form will need to be completed with the $10 fee.

 

Provide complete address
Provide complete address if applicable
Provide all numbers you are able to be contacted at. (Seperate the numbers by a comma.)