Fillable Update My Legal Name Step 1 Colorado Medical (Colorado DORA)

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Update My Legal Name Step 1 Colorado Medical (Colorado DORA)

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The Update My Legal Name Step 1 Colorado Medical (Colorado DORA) form is 1 page long and contains:

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  • 0 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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medical.marijuana@state.co.us www.colorado.gov/cdphe/medicalmarijuana
Revised August 2017
Step 1
You will need:
A copy of your Colorado ID with your new name
Copies of a certified marriage license, divorce decree, or other court documents to prove your name change
Patients without online access:
Email an online access request with this form
Print your new card once your name is updated
Patients under 18 or with legal representation:
Primary parent, legal guardian or legal representative must sign the form
Include a copy of primary parent, legal guardian or legal representative’s Colorado ID
Old
Middle initial
Last name
Step 2
New
Middle initial
Last name
Date of birth (mm/dd/yy)
First 5 of SSN (xxx-xx)
Telephone (000-123-4567)
Mailing address
Apt/Ste #
City
Zip code
County
Email (you will receive confirmation here)
Sign
I hereby certify that I, the patient, have verified the above information to be accurate and complete and no one
other than me (or my legally authorized representative) is submitting this request on my behalf. I understand
incomplete forms will be rejected.
Patient’s or Authorized Representative’s Signature
Typed signatures will not be accepted
Date
Attach
Copy of your Colorado ID with your new name
Copies of the documents proving your name change
Copy of parent, guardian or legal representative’s Colorado ID if you are a minor or have a legal
representative
Online access request if you don’t have online access and want to print your new card
Update My Legal Name
Colorado Medical Marijuana Registry
Email this form
Only for patients with a current registration
Apply online if your registration expired
Email
medical.marijuana@state.co.us
Download
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Email
Email completed PDF
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Email for others to sign
Print
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Update My Legal Name Step 1 Colorado Medical (Colorado DORA)

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Completed 15 March 2021

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