NAME CHANGE and/or
Licensure Unit 301 Centennial Mall South Lincoln, Nebraska 68509-4986 DHHS.LicensureUnit@
REQUIRED INFORMATION
Print the Name as it appears on your Current Credential:
Address:
Check if this is
a new address
Street/PO/Route: City:
Telephone - Optional: Date of Birth:
Social Security Number:
Credential Number:
Profession:
NAME CHANGE and/or
RE-ISSUANCE OF A CREDENTIAL
State:
Zip:
E-mail - Optional:
IF REQUESTING A NAME CHANGE, complete the following:
Print your new legal name:
ATTACH A COPY OF ONE OF THE FOLLOWING DOCUMENTS (required): Marriage license Divorce decree Court Order of legal name change Passport Other valid verification; print the name of this document: ________________________________________________
IF REQUESTING A RE-ISSUED CREDENTIAL check and indicate number of wall credentials you are
requesting:
Document Name
# Requested
4.5 x 7.25 wall credential
NOTE: YOU MUST SUBMIT $10.00 FOR EACH REISSUED CREDENTIAL REQUESTED.
Check one:
copy of current driver's license showing photograph and signature copy of passport showing photograph and signature other (specify)
A Wallet size credential may be printed at no cost at the following link:
Signature (required) All the statements on this request are true and correct.
_________________________________________ CredentialLicense Holder's Signature
______________________ Date
................
................
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