Illinois Department of Financial and Professional Regulation
Division of Professional Regulation
NAME AND ADDRESS CHANGE FORM
CONTACT INFORMATION: (As it Currently Appears On Your License)
NAME
ADDRESS
CITY, COUNTY, STATE, ZIP CODE
TELEPHONE #
Format: (000) 000-0000.
UPDATED ADDRESS INFORMATION:
NEW MAILING ADDRESS
(MUST BE A STREET ADDRESS, P.O. BOXES ARE NOT ACCEPTABLE)
CITY, STATE, ZIP CODE
TELEPHONE #
Format: (000) 000-0000.
FAX #
EMAIL ADDRESS
example@example.com
SIGNATURE (Required)
*
DATE
-
Month
-
Day
Year
Date
NAME CHANGE INFORMATION:
*Must include stamped or certified document (or photocopy of a stamped or certified) of one of the following:
marriage certificate
divorce decree
court order
naturalization document
* NEW NAME
*
SIGNATURE (Required)
*
DATE
-
Month
-
Day
Year
Date
If you have any questions, please contact our office at 800/560-6420.
Return Original To:
Illinois Department of Financial and Professional Regulation
Division of Professional Regulation - LAU
320 West Washington Street
Springfield, Illinois 62786
Fax: 217-557-8073
IL486-2377 10/19
LICENSE NO.
SOC. SEC NO.
EMAIL ADDRESS
example@example.com
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