Request For Change Of Name And/or Address, Duplicate License, Inactive License
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1Department of State
Bureau of Professional and Occupational Affairs
STATE BOARD OF NURSING
Mailing Address:
Telephone: 717‐783‐7142
State Board of Nursing
Fax: 717‐783‐0822
P.O. Box 2649
Harrisburg, PA 17105‐2649
email: st‐nurse@pa.gov
REQUEST FOR CHANGE OF NAME and/or ADDRESS, DUPLICATE LICENSE, INACTIVE LICENSE
Complete the following information for the license/certificate you hold. A separate form must be completed for each
license/certificate you hold. All information must be completed by the licensee.
CURRENT INFORMATION:
Last Name: _________________________________
Birth Date: _______________
First Name: _________________________________
Middle Initial: ____________
License No: _____________________
Expiration Date: _______________
Social Security No: ________________
Check here if you are an applicant.
ADDRESS CURRENTLY ON FILE WITH THE BOARD:
Street Address: ___________________________________________ City: __________________________________
State: ______________
Zip Code: _____________ Email Address: ______________________________________
Change Address to:
Street Address: ___________________________________________ City: __________________________________
State: ______________
Zip Code: _____________ Email Address: ______________________________________
Change of Name – You must submit a copy of a legal document verifying your new name. The following are
acceptable name change verification documents:
(1) marriage certificate;
(2) divorce decree which indicates the retaking of your maiden name;
(3) other legal document indicating the retaking of a maiden name;
(4) for a legal name change, a copy of the court document must be provided.
Change Name to:
Last Name: ___________________________ First Name: ______________________ Middle: _________________
Duplicate: A $5.00 fee per duplicate (check or money order) payable to “Commonwealth of PA”.
NOTE: Without the $5.00 fee, the change(s) will be made but no duplicate will be issued.
Inactive Status – I will not be practicing this profession in Pennsylvania and request inactive status. No fee is required.
SIGNATURE OF LICENSEE (Mandatory) ____________________________________________
DATE ______________
A processing fee of $20.00 will be charged for any check or money order returned unpaid by your bank, regardless of the reason for non‐payment.
REV. 10/2012
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Parent category: Legal