Fillable REQUEST FOR NAME CHANGE

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REQUEST FOR NAME CHANGE

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The REQUEST FOR NAME CHANGE form is 1 page long and contains:

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File type: PDF

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The
DISCIPLINARY BOARD
of the Supreme Court of Pennsylvania
Attorney Registration
601 Commonwealth Avenue, Suite 5600
PO Box 62625
Harrisburg, PA 17106-2625
Phone: (717) 231-3380
Fax: (717) 231-3381
atty.registration@pacourts.us
REQUEST FOR NAME CHANGE
You may not practice under a name other than that by which you are currently registered.
First
Middle
Last
(Name As Currently Registered)
First
Middle
Last
(Requested Name Change)
Attorney ID#:
Telephone:
E-Mail Address:
Effective Date of Name Change:
Document Authorizing Name Change:
Social Security Card (first 5 digits may be redacted)
Valid Passport
Court Order
Signature: Date:
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REQUEST FOR NAME CHANGE

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Completed 17 January 2022

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