Transcription of Name and Address Change Form Individual
1 Office of Market Regulation | Bureau of Licensing & Enforcement | Licensing Services Division 1209 Strawberry Square | Harrisburg, Pennsylvania 17120 Phone: | Fax: | Name and Address Change form (Revised 06/13) NAME AND Address Change form FOR INDIVIDUALS Name as it appears on license: Last Four Digits of Social Security Number: Date of Birth: License Number(s): Effective Date of Change : Business Email Address : Personal Email Address : Address Change Please use this form only if you are unable to submit your Address Change online at or New Home Address (street Address required): Phone Number: ( ) City State Zip Code Preferred Mailing Address (if different than above): City State Zip Code Business Name and Address (street Address required): Phone Number: ( ) Fax Number: ( ) City State Zip Code NAME Change Individual name changes can now be processed free of charge with the creation of a free ProducerEDGE account at Due to limited staffing and resources, we ask that you please utilize this service.
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