STEVE SISOLAK
Governor
STATE OF NEVADA
CANNABIS COMPLIANCE BOARD
www.ccb.nv.gov
1550 College Parkway, Suite 142
Carson City, Nevada 89706
Phone: (775) 687-6299
Grant Sawyer Office Building, Suite 4200
555 E. Washington Avenue
Las Vegas, Nevada 89101
HON. MICHAEL DOUGLAS
Chair
TYLER KLIMAS
Executive Director
Agent Change Form 6/15/2020 Page 1 of 1
Agent Registration Change Request
An agent must submit to the CCB a request for the change of address or change of name. This form
must be hand-signed. Electronic signatures will not be accepted. Include a copy of your valid
government-issued ID. E-mail CCBLicensing@ccb.nv.gov. Mail: Cannabis Compliance Board, Attn:
Agent Cards, P.O. Box 1948, Carson City, NV 89701
Agent
Registration Card # (Example: 180000111): ________________________________________________
Name of Agent (as shown on card) : _____________________________________________________________
Agent Name Change Information: Please include a copy of your valid government-issued ID card
which includes a photograph and the new name, and any documentation of the reason for the change.
New Name: ________________________________________________________________________________
Reason for name change (Example: Marriage): ____________________________________________________
Agent Address Change Information: Please include a copy of your valid government-issued photo ID.
Mailing Address: ___________________________________________________________________________
City: _________________________________________________________ State: __________ Zip: _________
Physical Address (if different than above): _______________________________________________________
City: _________________________________________________________ State: __________ Zip: _________
County of new address location: ________________________________________________________________
Phone: _______________________ Email Address: ________________________________________________
Effective Date of Change (when do you want this change to start?): ___________________________________
I certify that the information contained in this form is true and correct:
SIGNATURE OF AGENT: _____________________________________________ DATE_____________
Internal use only
Active Card and Number Verified:
Scanned to Agent Card Folder:
