CHANGE OF NAME REQUEST

CHANGE OF NAME REQUEST

Veterinary Practitioners Registration Board of Victoria
Information privacy: the Board will only use and disclose the personal information we collect in this form to change your name on the register: www.vetboard.vic.gov.au/privacy
Your Victorian registration number*
Name currently on account

First NameLast Name
Date of birth

DayMonthYear
Date
Email*
Mobile telephone*
Residential address*

Country
New name requested on register*
Reason for change of name*
Please specify other reason
UPLOAD certified copy of official change of name document, e.g. marriage certificate or deed poll. The back of the document must also be certified if there is information on it.*

Cancelof
UPLOAD certified copy of photo ID, e.g. passport page OR front AND back of driver's licence.*

Cancelof
I have the authority to make this request.The information provided in this change of name request is true and correct and I am the person named in the certified document(s) supplied with this form.
Confirm your declarations by writing your full current legal name
Your name will be updated within 5 business days of submission. Please verify that you are human and submit your request.*
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