Fillable Name Change Form DO NOT USE THIS FORM (New York State Education Department)

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Name Change Form DO NOT USE THIS FORM (New York State Education Department)

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The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Name Change Form
DO NOT USE THIS FORM IF YOU NEED TO CHANGE YOUR ADDRESS ONLY. IF YOU NEED TO CHANGE YOUR ADDRESS ONLY,
YOU MUST SUBMIT A CONTACT US FORM ON THE OFFICE OF THE PROFESSIONS' WEBSITE AT
https://eservices.nysed.gov/professions/contact-us/#/
Instructions: Use this form to report a change in your name. Read these instructions carefully and complete all applicable sections of this
form. Be sure to print clearly in ink. You must include acceptable supporting documentation. Acceptable supporting documentation
includes:
A photocopy of a court, marriage certificate, or divorce papers authorizing your name change and a photocopy of a photo ID in your new
name.
Or
Two (2) of the following sets of supporting documents:
●
A letter from the Social Security Administration indicating both your old and new names.
●
Copies of both old and new driver's licenses.
●
Copies of both old and new New York State non-driver photo ID cards.
●
Copies of both old and new Social Security Cards.
●
Copies of both old and new passports.
●
Copies of both old and new U.S. Military photo ID cards.
Other forms of identification may be acceptable as supporting documentation. Please contact the Records and Archives Unit by calling
518-474-3817 Extension 380 or by emailing oparchiv@nysed.gov before submitting.
Currently registered licensed professionals will be sent a new registration certificate. Also, if you would like to replace your existing license
parchment with one in your new name, check the appropriate box in Section II and enclose your original parchment (your original parchment
will be letter sized, 8.5 x 11 inches, and will not have your address on it). If your parchment has been lost, stolen or destroyed, be sure to
include a note to that effect.
Be sure to sign and date the affidavit in Section III before submitting the completed form along with any required documentation to
the Office of the Professions at the address at the end of the form.
Licensed professionals can check the Office of the Professions' web site at www.op.nysed.gov
to verify your name, city, state, registration
expiration date, and license number on record.
NOTE: Important information and registration renewals will be sent to the address on file for you. You must notify the Department in writing
within 30 days if your address or name changes.
Licensee business address, phone and email address are public information. Failure to indicate business or home on this form for each item will
deem it public information.
Section I - General Information
1. Name (currently on record)
2. Social Security Number
3. Birth Date
Month Day Year
4. Contact Information
Telephone Number
Home Business
Fax Number
Home Business
Current Email
Home Business
5. Type of change (check one)
Name Address Both
6. Effective date of change
(Note: Changes cannot be accepted until after the effective date)
7. Licensure status in New York State
I am an applicant for licensure in New York State for the
licensed profession* of
I am currently licensed in New York State in the
profession(s)* of (attach additional sheets if necessary)
New York State License Number
*For a list of professional titles licensed under Education Law, visit
the Office of the Professions' website at www.op.nysed.gov.
Name Change Form, Page 1 of 2, November 2019
Section II - Updated Information
Please sign the Affidavit in Section III using your NEW name. If you are currently registered you will receive a new registration certificate.
Name currently on record
Last Name
First Name
Middle Name or Initial
New Name
Last Name
First Name
Middle Name or Initial
Check here if you wish to have your existing license parchment replaced with one in your NEW name. Enclose your original parchment
and a $10 check or money order made payable to the New York State Education Department with your request. You will be sent a new
parchment. Note: your original parchment will be letter sized, 8.5 x x11 inches, and will not have your address on it.
Complete only if Applicable
Is this new address a Home address, or Business address
Licensee business address, phone and email address are public information. Failure to indicate if the new address is business or home will
deem it public information.
Address currently on record
Apartment/Building
Street
City
State
ZIP Code
Province or Country (If not U.S.)
New Address
Apartment/Building
Street
City
State
ZIP Code
Province or Country (If not U.S.)
Section III - Affidavit
I declare and affirm that the statements above are true, complete, and correct. I understand that any false or misleading information in, or in
connection with, my application or this notification may be cause for denial or loss of licensure and may result in criminal prosecution.
Signature Date
Applicants
Mail to:
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Unit, 89 Washington Avenue, Albany, NY 12234-1000
Indicate the profession you are applying for. For a list of professional titles licensed under Education Law, visit the Office of the
Professions' website at www.op.nysed.gov
Licensees
Mail to:
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Records and Archives Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Name Change Form, Page 2 of 2, November 2019
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Name Change Form DO NOT USE THIS FORM (New York State Education Department)

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Completed 30 August 2021

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