Change of Address Form
Chan
ges must be mailed.
Mail
this form to: Faxes are not accepted
NCBLCMHC
PO Box 77819
Greensboro NC 27417
Please print your first, middle and last name, along with your license number (if applicable), to help in
finding your records in our database.
First Name Middle Name Last Name
___________________________ __________________________ ____________________________
NCBLCMHC Lic
ense# OR SS # _______ - _______ - _______
Old Address
HOME ADDRESS
Street 1)
Street 2)
City State ZIP
Phone ( ) Fax ( )
Email
WORK ADDRESS
Street 1)
Street 2)
City State ZIP
Phone ( ) Fax ( )
Email
Thi
s form must be signed by the licensee/applicant in order to be processed.
_________________________________________________ _____ _________
Signature Date
There is no charge for changing your address with the Board. The Board requires all licensees and
applicants maintain a current address on file with the Board office. Changes of address should be
submitted within 60 days of move.
P.O. Box 77819 | Greensboro, North Carolina 27417
