Fillable Name Change (Commonwealth of Massachusetts)

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Name Change (Commonwealth of Massachusetts)

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The Name Change (Commonwealth of Massachusetts) form is 1 page long and contains:

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  • 5 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Name Change and Duplicate License Request, Page 1 of 1, Rev. 5/19
Commonwealth of Board of Registration in Medicine
200 Harvard Mill Square, Suite 330 – Wakefield, MA 01880
Telephone: (781) 876-8210 Fax: (781) 876-8383
www.mass.gov/massmedboard
NAME CHANGE AND DUPLICATE LICENSE REQUEST
INSTRUCTIONS: Complete the following information and submit copies of the required documentation to
support your name change request. Return form to the attention of the Licensing Division at the above address.
NAME CHANGE INFORMATION
Former Name
Last First Middle
New Name
Last First Middle
Mailing Address
Number and Street
City State/Province/Territory Zip (or postal) Code
MA License #
Date of Birth
_______ ______ _______
Month Day Year
REQUIRED DOCUMENTATION
You must submit photocopies of the following two required documents:
1. A current government issued photographic identification (e.g., driver license, passport, etc.); AND
2. One of the following additional legal documents as proof of name change:
Certified Court Order
Marriage Certificate
Divorce Decree
If you currently hold a full license in Massachusetts, you must also submit the following:
Original wall certificate; AND
Wallet sized license card.
ATTESTATION
Under the penalties of perjury, I declare that to the best of my knowledge and belief, the information contained herein and
evidence submitted herewith are true, correct and complete. I understand that any falsification or misrepresentation of any
item on this form or any attachment hereto may be a sufficient basis for denying or revoking a license.
SIGNATURE: _________________________________________________ DATE: _________________________
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Name Change (Commonwealth of Massachusetts)

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Completed 18 July 2020

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