Change Requests

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.   

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