BOARD OF TECHNICAL REGISTRATION - AZ

State of Arizona

BOARD OF TECHNICAL REGISTRATION

1110 W. Washington Suite 240 Phoenix, Arizona 85007 (602) 364-4930 FAX: (602) 364-4931 btr.

CHANGE OF ADDRESS FOR APPLICANTS AND REGISTRANTS

PLEASE TYPE OR PRINT LEGIBLY

Name:

Registration or Application Number(s):

(Please Print)

Today: / /

(Month) (Day) (Year)

NOTE: If you have more than one registration/application, please list all numbers affected by

the change. By law, if you only provide the AZBTR with a residence address, your residence address will become available to the public. A.R.S .? 32-3801

Mailing Address:

Phone No. connected to mailing address: (

)

Business Address:

same as mailing

Phone No. connected to business address: (

)

Residence Address:

same as mailing

Phone No. connected to residence address:(

)

Preferred Email Address: Alternative Email Address:

Effective Date of Change:

/ /

(Month) (Day) (Year)

IT IS IMPORTANT TO KEEP YOUR ADDRESS CURRENT WITH THE BOARD. PLEASE FILL OUT A CHANGE OF ADDRESS AND RETURN AS SOON AS POSSIBLE.

SIGNATURE

Revised 10/13/2017

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