Commonwealth of Massachusetts
Division of Professional Licensure
<Board Name>
1000 Washington Street • Suite 710
Boston • Massachusetts • 02118-6100
All requests should be mailed to the address listed above.
Please check the appropriate boxes
NAME CHANGE ADDRESS CHANGE DUPLICATE LICENSE
T T T
Under the penalties of perjury, I declare that the information provided herein is a truthful
and complete statement of the information required.
Print/type clearly the information as it is
NOW SHOWN on your license:
Print/type clearly the information as you wish it to
appear on your DUPLICATE license:
Name: Name:
Address: Address:
City/Town: City/Town:
State: State:
Zip Code: Zip Code:
OTHER REQUIRED INFORMATION
License No: Date of Birth:
Type of License: Signature:
Expiration Date: Telephone Number:
Last four digits of SSN (Mandatory): Date:
1. For name change or duplicate license, you MUST return your current license with this form. If your
current license has been lost or stolen, please check here.
2. For address changes only, DO NOT
return your current license. All addresses are subject to
disclosure upon request, M.G.L. c4,s7.
3. M
AKE YOUR CHECK OR MONEY ORDER PAYABLE TO THE “COMM. OF MASS.” DO NOT SEND CASH.
Please check the appropriate box: Fee FOR OFFICIAL USE ONLY
Duplicate license WITH OR
WITHOUT an address change
$17.00 Fee:
Duplicate license WITH a name change $27.00 Date Received:
Name or address change WITHOUT
duplicate license
$0.00
Received by:
TELEPHONE: 617-727-<extension> http://www.mass.gov/dpl/boards/<board code>
Hearing Instrument Specialists
http://www.mass.gov/dpl/boards/he
