DBPR 0080 – Request for Address or Name Change
DBPR 0080 ? Request for Address or Name Change
STATE OF FLORIDA DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
Transaction Type: Name Change (individual) Name Change (business) Change Mailing Address
License Number Licensee Name (previous) Licensee Name (new)
Street Address or P.O. Box
SELECT TRANSACTION TYPE Change Contact Information (phone and/or email) Change Physical Address
LICENSEE INFORMATION
NEW MAILING ADDRESS
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
Primary Phone Number
NEW CONTACT INFORMATION Primary E-Mail Address
NEW PHYSICAL ADDRESS (IF DIFFERENT THAN MAILING ADDRESS) Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
NEW ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
I affirm that I have provided the above information completely and truthfully to the best of my knowledge.
Licensee Sign Here:
Date:
Please mail to: Department of Business and Professional Regulation
C/O Central Intake Unit 2601 Blair Stone Road Tallahassee, FL 32399-0786
Or fax to: 850.488.8040
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