Name Change Form

Name Change Form
To uphold the integrity of the Board Certification credential, any changes or alterations to the name of candidates/certficants must be formally submitted to the IBSC. This submission must include a copy of the paramedic license/certificate issued by either the NREMT or a recognized State or Country, reflecting the updated name. Upon receipt of these documents, the candidate/certificant will receive acknowledgment of the request. Within 30 business days from receipt, confirmation of the name change will be provided to the candidate/certificant.

You will be able to download the completed from at the end. This online form must be completed for any name change request. ALL FIELDS REQUIRED.
Certification Number(s)*
Former Name*

First NameMiddle NameLast Name
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
Email Address*
New Name*

First NameMiddle NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Phone Type*
Home, Office, Cell
Upload a copy of your paramedic license/certificate from either the NREMT or a State or Country showing the name change*

Cancelof
DATE*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below, I affirm that all statements provided herein are true and accurate to the best of my knowledge and belief. Signature*

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