Change Of Name Notification (Page 2 of 2) in pdf

Change Of Name Notification Page 2

Change of Details (please print clearly)

Current registration number:_________________

Current Name

Title ()

Miss Other_______________

Dr

Mr

Mrs Ms

Given name

Middle name(s)

Family name/surname

Date of birth (dd/mm/yyyy)

New Name

Title ()

Miss Other_______________

Dr

Mr

Mrs Ms

Preferred first name

First name

Middle name(s)

Surname

Please note: A certificate from a marriage ceremony is not accepted in support of a name change request. A

marriage certificate issued by a State or Territory Registry of Births, Deaths and Marriages is accepted.

If you have any queries about the completion of this form please contact the TRBWA Customer Service Team for

assistance (e: info@trb.wa.gov.au; t: (08) 9230 0600; regional callers 1300 652 911).

Preferred email

(please print one character per box)

Alternate email address

(please print one character per box)

PLEASE NOTE:

The TRBWA will use this email address as your registered email address for contact purposes. During the

application process it is your responsibility to inform the TRBWA of any changes to your contact details.

2014/09241

Change of Name

Issued 16/12/2014

Uncontrolled when printed

Page 2 of 2

Change Of Name Notification Page 2