Fillable Printable Name And Address Change Form - New York
Fillable Printable Name And Address Change Form - New York
Name And Address Change Form - New York
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
ADDRESS/NAME CHANGE FORM
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.
• 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 e-mailing [email protected]. Your records will be updated.
Currently registered licensed professionals will be sent a new registration certificate.
• For name changes only
: Complete Sections I, III, and IV. Name changes must be accompanied by supporting documentation.
Acceptable supporting documentation includes:
A photocopy of a court, marriage certificate, or divorce papers authorizing your name change and a photocopy of a photo ID in your new
name.
Or
Two (2) of the following sets of supporting documents:
• A letter from the Social Security Administration indicating both your old and new names.
• Copies of both old and new driver ’s licenses.
• Copies of both old and new New York State non-driver photo ID cards.
• Copies of both old and new Social Security Cards.
• Copies of both old and new passports.
• Copies of both old and new U.S. Military photo ID cards.
Other forms of identification may be acceptable as supporting documentation. Please contact the Records and Archives Unit by calling
518-474-3817 Ext. 380 or by e-mailing [email protected] before submitting.
Be sure to sign and date Section IV. Currently registered licensed professionals will be sent a new registration certificate. Also, if you
would like to replace your existing license parchment with one in your new name, check the appropriate box in Section III and enclose
your original parchment (your original parchment will be letter sized, 8.5 x 11 inches, and will not have your address on it). If your
parchment has been lost, stolen or destroyed, be sure to include a note to that effect.
• For address and name changes
: Complete all sections.
Licensed professionals can check the Office of the Professions' Web site at www.op.nysed.gov to verify your name, city, state, registration
expiration date, and license number on record.
NOTE: Important information and registration renewals will be sent to the address on file for you. You must notify the Department in
writing within 30 days if your address or name changes.
Licensee
business address, phone and e-mail address are public information. Failure to indicate business or home on this form
for each item will deem it public information.
Section I: Your General Information
1. Name (currently on record):
2. Social Security Number: Birth Date: Month Day Year
Telephone: Home: Business:
Fax:
E-mail Home or Business:
3. Are you reporting an address and/or name change? address change name change both
4. Effective date of change: (Note: Changes cannot be accepted until after
the effective date.)
5. Licensure status in New York State:
I am an applicant for licensure in New York State for the licensed profession(s) of:
I am currently licensed in New York State in the profession(s) of:
(see list of professions on our web site at www.op.nysed.gov)
(see list of professions on our web site at www.op.nysed.gov)
New York State license number:
New York State license number:
Address/Name Change Form, Page 1 of 2, Rev. 6/15
OFFICE USE
FORM AD/NAME
Section II: Address Change (please print)
Is this new address a
Home or
Business address?
Section III: Name Change (please print) If you are reporting a name change, please sign using your NEW name in Section lV. If you are
currently registered you will receive a new registration certificate.
Check here if you wish to have your existing license parchment replaced with one in your NEW name. Enclose your original
parchment and a $10 check or money order made payable to the New York State Education Department with your request. You will
be sent a new parchment. Note: your original parchment will be letter sized, 8.5 x ll inches, and will not have your address on it.
Section IV: Affidavit
I declare and affirm that the statements above are true, complete, and correct. I understand that any false or misleading information in, or in
connection with, my application or this notification may be cause for denial or loss of licensure and may result in criminal prosecution.
_____________________________________________________________________________ _________________________________
Signature Date
Applicants New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
mail
to Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Indicate the profession you are applying for. For a list of professional titles licensed under Education Law, visit our web site at
www.op.nysed.gov
Licensees New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
mail
to Records and Archives Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Address/Name Change Form, Page 2 of 2, Rev. 6/15
Failure to answer this question will result in your address being deemed a business address and, therefore, public information.
Information Currently On Record
Apt./Bldg.
Street
City
State
Zip Code
Province or Country (if not U.S.)
Information Currently On Record
Last Name
First Name
Middle or Initial
New Information
Last Name
First Name
Middle or Initial
New Information
Apt./Bldg.
Street
City
State
Zip Code
Province or Country (if not U.S.)
