Name Change

Name Change

For name changes, legal documentation must be provided supporting the name change. Examples include marriage certificates, legal name change documents, etc. Documentation must include previous name and new name.
Name under which you attained certification

First NameLast Name
New Legal Name

First NameLast Name
Certificant Number
Email
example@example.com
Name exactly as you wish it to appear on the certificate.
Scope(s) of Certification
Certification Expiration Date

MonthDayYear
Date
Please upload your legal documentation for your name change. Please do not upload a drivers license, social security card, or other sensitive records. The record will be used to confirm name change only and will not be retained in the cerificant's record.

Cancelof
Do you want a replacement certificate? Replacements are $15 per certificate. Payment must be received before a new certificate will be issued.

YesNo
Will you pay online or by mailing a check?

OnlineCheck
You may pay online via PayPal by following this link: Certificate Replacement Fee
Checks should be mailed to:

Gretchen Lajoie

ABC Registrar

P.O. Box 418

Gardiner, ME 04345
Signature

Clear
Proof Provided

Marriage LicenseDivorce DecreeLegal name changeOther
Name Change Granted by Registrar

GrantedNot Granted
Comments
Should be Empty: