New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Change of Address Form for a Professional License
Please print the new address(es) below.
____________________________________________________________________________________________________________
Last Name First Name Middle Name or Initial
License Number: ____ ____ ____ ____ ____ ____ ____ ____ Profession: _______________________________________________
(Alpha letters plus the six-digit license number)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application (including your address of record) may be subject to public disclosure as
required by the Open Public Records Act (OPRA).
Home: _____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ___________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Please mail this form to: State Board of Professional Engineers and Land Surveyors, P.O. Box 45015, Newark, NJ 07101, or fax
it to 973-273-8020.
Certication: Under penalties of perjury, I declare that the change-of-address information indicated above is true, complete
and correct.
Sign Here:__________________________________________________________________________ Date: _____ /______ /______
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