ACEM name change notification

ACEM name change notification
Form No: F964

Last Revised: August 2025

Version: v1
ACEM ID*
Email*
example@example.com
Reason for name change*
First name*
First name as currently recorded in the ACEM Portal
Has there been a change to your first name?*

YesNo
New first name*
Middle name*
Middle name as currently recorded in the ACEM Portal
Has there been a change to your middle name?*

YesNo
New middle name*
Surname*
Surname as currently recorded in the ACEM Portal
Has there been a change to your surname?*

YesNo
New surname*
Are there any other changes required to your name or ACEM Portal profile?*

YesNo
Please detail additional changes needed*
To update your name on your ACEM Portal profile, you must provide certified copies of your original name change documents. Your updated name must also match the name registered with AHPRA or MCNZ.

A certified copy is a copy of an original document that has been verified as true by an authorised certifier. To obtain this, make a copy of your original document and take both to an Authorised Officer, who will compare them and certify the copy.

If your name change is due to divorce, please provide your birth certificate along with documentation confirming your divorce, or documents showing both your married and birth names.
Please upload the certified copies here:*

Cancelof
Signature*

Clear
Date*

DayMonthYear
Date
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