New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Architects
124 Halsey Street, 3rd Floor, P.O. Box 45001
Newark, New Jersey 07101
(973) 504-6385
Change-of-Address Form for a
Professional Licensed Architect, Landscape Architect
& Certied Interior Designer
Please print clearly.
____________________________________________________________________________________________________________
Last name First name Middle initial
License number: ____________________________________ Profession: ________________________________________________
(Please include alpha letters plus the eight-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 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:
New Jersey State Board of Architects
P.O. Box 45001
Newark, NJ 07101
or fax to: 973-504-6458
Certication
Under penalties of perjury, I declare that the change-of-address information indicated above are true, complete and correct.
_________________________________________________ ________________________
Licensee’s signature Date
click to sign
signature
click to edit
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