Transcription of Name Change Form
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Name Change Form
The University of the State of New York The State Education Department Address/Name Change Form Office of the Professions Division of Professional Licensing Services Instructions: Use this form to report a Change in your address and/or name. Please read these instructions carefully and be sure you complete the appropriate sections of this form. Please print clearly in ink. o For address changes only: Complete Sections I, II, and IV. For address changes only, you may fax this form to the Records and Archives Unit at 518-486-3617 or provide the required information by emailing Your records will be updated. Currently registered licensed professionals will be sent a new registration certificate.
Use this form to report a change in your name. Read these instructions carefully and complete all applicable sections of this form. Be sure to print clearly . in ink. You must include acceptable supporting documentation. Acceptable supporting documentation includes:
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