Name Change Request Form (For Dental Assistants) printable pdf download

Texas State Board of Dental Examiners

333 Guadalupe, Tower 3, Suite 800

Austin, Texas 78701-3942

NAME CHANGE REQUEST FORM

Phone: (512) 463-6400

Fax: (512) 463-7452

(FOR DENTAL ASSISTANTS)

INSTRUCTIONS:

NON-REFUNDABLE FEE

1. Use this form to change your name when you are NOT renewing your registration(s).

SEE FEE

2. Display Legal Full Name: Certificates must display the registrants Full Legal Name.

SCHEDULE BELOW

3. Legal Documentation: Legal documentation of the change, i.e., marriage license,

divorce decree, court order, etc.)

4. Fees: The fee you pay is based on the type of certificate(s) you hold. (See Schedule Below). Pay by check, money order or cashier’s

check (do not send cash). Please make payment payable to the Texas State Board of Dental Examiners.

5. Processing and Receiving Your Certificate. Please allow two weeks for processing. Your certificate will be mailed to your address on

file with the State Board of Dental Examiners (SBDE). If your address has changed, include a SBDE Change of Address Form with this

request form to avoid delays in receiving your certificate.

CURRENT INFORMATION:

________________________________

(BEFORE CHANGE)

SOCIAL SECURITY NUMBER

______________________________ _____________________________ ________________________________

FIRST NAME

MIDDLE NAME

CURRENT LAST NAME

(Before Change)

____________________________________________________________ ___________________________________ ____________ _____________

ADDRESS

CITY

STATE

ZIP

__________________________________

________________________________________

E-MAIL ADDRESS

PHONE NUMBER

TEXAS CERTIFICATES:

CHECK ONLY THE CERTIFICATE(S) YOU CURRENTLY HOLD AND ENTER YOUR CERTIFICATE NUMBER.

___

____



RDA Number: ___________________

Coronal Polishing Number: _________________

____



____ Pit & Fissure Sealant Number: _________________

Nitrous Monitoring Certificate Number: ________________

NEW INFORMATION

(AFTER CHANGE)

______________________________ _____________________________ _________________________________

FIRST NAME

MIDDLE NAME

NEW LAST NAME

(After Change)

FEE SCHEDULE

A NEW CERTIFICATE WILL BE ISSUED BASED ON THE CERTIFICATES YOU CURRENTLY HOLD.

I also hold this

I hold this Certificate

PAY

Certificate

RDA Certificate Only

$25.00

RDA Certificate and

Pit & Fissure Sealant Cert

$25.00

RDA Certificate and

Coronal Polishing Cert

$25.00

RDA Certificate and

Nitrous Monitoring Cert

$25.00

RDA Certificate and