Name Change Form

Name Change Form
This form is used to request a name change on your American Medical Technologists (AMT) account. The information and supporting documentation requested are necessary to verify your identity, confirm the requested change, and ensure your certification records remain accurate and up to date.

Requests submitted without the required supporting documentation will not be processed.
Current Name on File & AMT ID #
Name on Account

First NameLast Name
AMT ID Number
Contact Information
Email
example@example.com
Cell Phone Number
Format: (000) 000-0000.
Address

Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
New Information
Prefix
Change Name To:
Supporting Documentation
Please attach a document showing your legal name change, such as a marriage certificate, divorce decree, or court order.

The documentation must show your previous and updated name so AMT can verify and process your request.

Please submit only documentation relevant to your name change request. Remove or redact any sensitive information not needed to evaluate your request.
Supporting Documentation Attached
Supporting Documentation

Please attach either PDF, jpg or word documents files as documentation.
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Optional comments
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