Request for Name Change- Replacement Licence or Certificate Required


Log in to prefill profile information

Please fill out and submit with the appropriate fee for a replacement licence and/or certificate.

Personal Information

TO (Name As It Appears on Supporting Document)

Mailing Address

Phone Number

Effective Date of Name Change

Supporting Document Information

Please upload at least one of the documents listed below

Legal Document Type
  
  
  
Upload Supporting Document

To upload more than one file at a time:
• Click the Browse button, a file window will open
• Click the first file you want to upload
• Press and hold the Ctrl key on your keyboard
• While holding down the Ctrl key, click each of the other files you want to upload
• When finished selecting files click Open

Type of Replacement Request

*Please be advised that the $21.00 is applicable for EACH replacement document
*If you are requesting a replacement of both your license AND certificate, the amount in the payment portion should be updated to reflect the additional replacement fee


Total Amount: $0.00

Payment Method
Credit Card Information

Billing Information