I do hereby afrm that the above information is true, accurate and complete.
_____________________________________
Date
________________________________________________________
Original Signature
ISBE 73-71 (3/20)
Directions:
Please print or type the information requested, and sign in ink. Return this completed form to the address above. You can
also email your form and required documentation to licensureforms@isbe.net.
NAME (Last, First, MI, Maiden)
IEIN
DATE OF BIRTH (MM/DD/YYYY)
CURRENT ADDRESS (Street, City, State, Zip Code) TELEPHONE (Include Area Code)
E-MAIL
!73-71!
PART I NAME CHANGE – Attach a copy of an ofcial document verifying the name change.
CHANGED FROM CHANGED TO
PART II DATE OF BIRTH CORRECTION – Attach a copy of an ofcial document verifying the correct date of birth.
CHANGED FROM CHANGED TO
PART III SOCIAL SECURITY NUMBER CORRECTION – Attach a copy of an ofcial document verifying the correct social security number.
CHANGED FROM CHANGED TO
100 North First Street, E-240
Springeld, Illinois 62777-0001
LICENSURE UPDATE REQUEST
EDUCATOR EFFECTIVENESS DEPARTMENT
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