STATE OF CALIFORNIA
DEPARTMENT OF CONSUMER AFFAIRS
NOTIFICATION OF NAME CHANGE
The California Department of Consumer Affairs may recognize a name change by an applicant
or licensee if that name is now his or her legal name for all purposes and if the change is not
made for fraudulent purposes and is not misleading to the public.
Important Submission Information:
Submission of this form will serve as a notification of name change to all California
Boards and Bureaus operating on the BreEZe system. For a complete listing of which licensing Boards and Bureaus this name
change will affect, please see the back of this form. Incomplete packets will not be accepted or returned.
SECTION A: NAME CHANGE INFORMATION
Former First Name Former Middle Name Former Last Name
New First Name New Middle Name New Last Name
Last Four of SSN# License # Date of Birth (MM/DD/YYYY)
SECTION B: DOCUMENTATION REQUIREMENTS AND OPTIONS
You must submit photocopies or electronic copies of the following two required documents:
1. A current government issued photographic identification (e.g., driver license, alien registration, passport,
etc.) AND 2. One of the following additional legal documents as proof of name change. Check one and attach a
copy of the document.
Certified Court Order
Dissolution of Marr
SECTION C: PERSONAL ATTESTATION
I declare under penalty of perjury under the laws of the State of California that the information given above is
true and correct and that I am the person who was issued the original California license by the Department of
Consumer Affairs or submitted an application.
I hereby certify that the name change is not made for fraudulent purposes.
Dental Board of California
2005 Evergreen Street, Suite 1550
Sacramento, CA 95815
click to sign
click to edit