__________________________________ ______________________________________
Application for Duplicate License or Name Change
Complete this form and submit to the Board at the address below with $50.00 (check or money order) made
payable to "BOCE". If you are requesting a name change, legal documents verifying the name change must
accompany this form. If you are requesting a duplicate license, due to an address change, please return your old
licenses with this form. If you are requesting active status, please submit with the inactive to active
application form.
License Number:
DC/CORP
Name: Last First Middle
Address: Number Street
City State Zip Code
Practice Address: Number Street
City State Zip Code
Work Telephone Number:
( )
E-mail Address (optional)
DUPLICATE LICENSE
Please check the appropriate box to indicate why you are requesting a duplicate license:
From Inactive to Active Lost Stolen Destroyed Change of Address
LEGAL NAME CHANGE
(attach legal/court order documents)
New Name: First______________________________Middle___________________________Last_____________________________
Reason for name change:
Marriage Divorce Court Order
AFFIDAVIT
I declare under penalty of perjury under the laws of the State of California that the Foregoing is true, correct and
complete to the best of my knowledge.
Signature of Licensee
Date
Rev. 12/18
BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
DEPARTMENT OF CONSUMER AFFAIRS • CALIFORNIA BOARD OF CHIROPRACTIC EXAMINERS
901 P St., Suite 142A, Sacramento, CA 95814
P (916) 263-5355 | Toll-Free (866) 543-1311 | F (916) 327-0039 | www.chiro.ca.gov
