CHANGE OF NAME REQUEST

CHANGE OF NAME REQUEST

Veterinary Practitioners Registration Board of Victoria
Your Victorian registration number*
Name currently on the register

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
YOU MUST GET THE FOLLOWING DOCUMENT CERTIFIED AS A TRUE COPY OF THE ORIGINAL by a person authorised to certify documents, e.g. another practising veterinary practitioner (not related to you), a pharmacist, police officer or lawyer. DOCUMENT: high quality colour PDF 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.*

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YOU MUST GET THE FOLLOWING DOCUMENT CERTIFIED AS A TRUE COPY OF THE ORIGINAL by an authorised certifier of documents: DOCUMENT: high quality colour PDF cop of photo ID, e.g. passport page OR front AND back of driver's licence.*

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Tick boxes below to make the following declarations:*

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 declarations by writing your full current legal name, i.e. your new name
Please verify that you are human*
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