DEPARTMENT OF BUSINESS & INDUSTRY - Nevada Division …



Name Change Form

(Please print or type)

Residents of Nevada provide a copy of a marriage certificate, divorce decree, driver’s license or any other legal document granting the name change.

Nonresidents provide a copy of documentation demonstrating the name change in their resident state.

|Previous name: |

| Soc. Security Number | If applicable, NASD Individual Central Registration Depository (CRD) Number |

| Are you affiliated with a financial institution/bank? |

|Yes No |

| Last Name JR./SR. etc | First Name | Middle Name | Date of Birth |

| | | |(month) ____ (day) ____ (year)_____ |

| Residence/Home Address (Physical Street) | P.O. Box | City | State | Zip or Foreign Country |

| Home Phone Number | Gender (Circle One) | Are you a Citizen of the United States? (Check One) |

|( ) - |Male Female |Yes No (If No, of which country are you a citizen?) |

| | |(If No, you must supply work authorization) |

| Personal Business Name (dba) (Provide Nevada County Clerk Filing if you have a physical location in Nevada) |

| Business Address (Physical Street) | P.O. Box | City | State | Zip or Foreign Country |

| Business Phone Number | Business Fax Number | Business E-Mail Address | Business Web Site Address |

|( ) - |( ) - | | |

| Applicant’s Mailing Address | P.O. Box | City | State | Zip or Foreign Country |

| If Applicable, beginning date of residency in the State of Nevada: Nonresidents: “Home State” where you hold a |

|Resident License |

|_________Month __________Day __________Year __________________________________________ |

| |

NDOI 210 DOC 328 Individual Name Change (rev 1.17.2020)

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Department of Business and Industry

Nevada Division of Insurance

1818 E. College Parkway, Ste 103, Carson City, Nevada 89706 Phone: (775) 687-0700 Fax: (775) 687-0787 Web: doi.state.nv.us

Division Use Only: Application ID#: _____________ ORG ID # __________ Approved by: _________________ Date: __________________

License No: ________________________________________

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