Commonwealth of Massachusetts
Division of Professional Licensure
Office of Public Safety and Inspections
1000 Washington St.,Suite 710•Boston•Massachusetts•
02118
Revised August 2017
REQUEST FOR DUPLICATE RENEWAL FORM
P
LEASE COMPLETE THIS FORM AND MAIL TO THE ADDRESS ABOVE
ATTN: REQUEST FOR DUPLICATE RENEWAL FORM
OR
F
OR IMMEDIATE ASSISTANCE, PLEASE EMAIL THIS COMPLETED FORM
OR THE REQUESTED INFORMATION TO
DPSINFO@STATE.MA.US
WITH THE SUBJECT LINE “REQUEST FOR DUPLICATE RENEWAL FORM”
Failure to do
so will result in your license renewal being delayed and/or expiring until the proper
documentation is provided. Licenses not renewed by the expiration date shall become void, and shall
after one year be reinstated only by a new application and re-examination of the licensee if required.
Name: ________________________________________________________________
License Number: _______________________________________________________
License Type: __________________________________________________________
Expiration Date: _______________________________________________________
Would you like to have your renewal form e-mailed to you?
□ YES □ NO
If so, please specify the E-mail Address you want your renewal notice to be sent to:
______________________________________________________________________
