Arizona State Board of Pharmacy
Physical Address: 1616 W. Adams, Suite 120, Phoenix, AZ 85007
Mailing Address: P.O. Box 18520, Phoenix, AZ 85005
P) 602-771-2727 F) 602-771-2749
License/Permit No.
Check #
Receipt #
Name Change Request
This form is intended for licensees (technicians/pharmacists/interns) who wish to change the name on their license. To change your
name, please complete this form and submit it with a copy of the legal document that shows your name change and a check or
money order for $10.00. Acceptable documents include your marriage license, divorce decree or court order. Please make your
check or money order payable to the Arizona State Board of Pharmacy.
Once your name change has been processed, you will receive a white paper copy of your license. You may order updated relief or
wall certificates for an additional $10.00 per certificate. Please indicate the number of certificates requested below.
Name (as it appears on your license):
License No.: Date of Birth.:
Mailing Address:
City: State: Zip:
New Name:
Document Provided:
Marriage License
Divorce Decree
Additional Certificates (#)
Duplicate License
Relief Certificate