NAME AND ADDRESS CHANGE FORM - State of Illinois
Illinois Department of Financial and Professional Regulation Division of Professional Regulation
NAME AND ADDRESS CHANGE FORM
CONTACT INFORMATION: (As it Currently Appears On Your License)
LICENSE NO._____________________
NAME ________________________________________________________ SOC. SEC NO.____________________
ADDRESS_______________________________________________________________________________________
CITY, COUNTY, STATE, ZIP CODE ___________________________________________________________________
TELEPHONE # ____________________________ EMAIL ADDRESS_______________________________________
UPDATED ADDRESS INFORMATION:
NEW MAILING ADDRESS __________________________________________________________________________ (MUST BE A STREET ADDRESS, P.O. BOXES ARE NOT ACCEPTABLE) CITY, STATE, ZIP CODE ___________________________________________________________________________ TELEPHONE # ____________________________ FAX # ____________________________ EMAIL ADDRESS ______________________________________________ SIGNATURE (Required)_________________________________________ DATE _______________________________
NAME CHANGE INFORMATION:
*Must include stamped or certified document (or photocopy of a stamped or certified) of one of the following:
marriage certificate divorce decree
court order naturalization document
* NEW NAME ____________________________________________________________________________________
SIGNATURE (Required)_________________________________________ DATE _______________________________
If you have any questions, please contact our office at 800/560-6420.
Return Original To:
Illinois Department of Financial and Professional Regulation Division of Professional Regulation - LAU 320 West Washington Street Springfield, Illinois 62786 Fax: 217-557-8073
IL486-2377 10/19
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