________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
STATE OF CALIFORNIA – DEPARTMENT OF CONSUMER AFFAIRS – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY GAVIN NEWSOM, GOVERNOR
1747 N. Market Blvd., Suite 180
Sacramento, CA 95834
P
916.515.5200
F
916.928.2204
www.acupuncture.ca.gov
NOTIFICATION OF ADDRESS CHANGE
Each person holding a license, registration, approval or any other authority issued under
this chapter shall file his or her proper and current mailing address with the board, and shall
notify the board, in writing, within thirty (30) days of any and all changes of mailing address,
giving both the old and new address. (C.C.R. Title 16, Section 1399.406)
NAME: _______________________________________ LICENSE NO. ____________
OLD ADDRESS OF RECORD*
Number Street Name Apt/Suite No.
City State Country Zip Code
NEW ADDRESS OF RECORD*
Number Street Name Apt/Suite No.
City State Country Zip Code
___________________________________ (_____)__________________ __________
Signature Phone Number Date
* “Address of Record” is the address that appears on your pocket license, on the board’s
licensing screen and website. All correspondence from the board is mailed to this address,
and it is made available to the public for purposes of mailing lists and/or license
verification.
REV 5-2019
