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.   

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  Name Change Request 

  Fillable Form
  

• ​Change of Address Request Fillable Form​​
  

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

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  Name Change Request Online Application

• Change of Address Request Online Application

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  Email/Phone Change Request Online Application

• ​Replacemen​t License Request Online Application​
  

• Inactive Status Form​​