Name Change Form
You must Mail name changes, faxed copies are not acceptable.
Mail this form to: NCBLCMHC
PO Box 77819
Greensboro NC 27417
Please be sure to attach copies of all legal documentation, such as marriage certificate, divorce papers, or other court
documents in order for the Board to process your name change request. Changes must be submitted with 60 days of
change.
LCMHC # OR Last four of SS #
Previous Name
New Name
Other Divorce Decree _Marriage Certificate Documentation Enclosed: ___ ___ __
This form must be signed by the licensee/applicant in order to be processed.
Signature Date
If you would like to request a duplicate license with the new name, please complete the Request for Duplicate
License Form below.
Request for Duplicate License Form
Duplicate licenses may be obtained by sending this form with $15 payment (check, money order or credit card info) to the
address above.
If your name has changed, the Board does not require you to obtain a license with your new name. However, if you wish
to obtain one, mail this form along with the Name Change form and payment to the address listed above.
Name
Address
City/State/ZIP
credit card
check (#I am paying by: ___ ) ___
Amount paid: $ Amount to be charged: $
MasterCard Expiration Date:VISA CC Type: ___ ___
CC #:
Cardholder’s Signature (required)
