National Association Of Boards Of Pharmacy Social Security Number Change Notice
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1National Association of Boards of Pharmacy
1600 Feehanville Drive • Mount Prospect, IL 60056-6014
Tel: 847/391-4406
• Fax: 847/375-1114
Web Site:
• E-mail: custserv@nabp.net
Social Security Number Change Notice
For security reasons, documents can only be sent to NABP via mail.
Complete and hand sign this form in front of a notary and make a copy for your file. Please type or print legibly. Mail this signed
and notarized original form, along with a photocopy of your Social Security documentation (Social Security card) to NABP
Customer Service, at the address above.
Your Name: ________________________________________ Date of Birth: ________________________
Your Signature: __________________________________ NABP e-Profile ID: ________________
(if applicable)
Pharmacist/Technician License No.: __________________________ State: ________________
(if applicable)
Mailing Address: _________________________________________________________________________
Phone Number:
_______________________ E-Mail Address: ___________________________________
Reason for Change: ______________________________________________________________________
Corrected Social Security Number: __________________________________________________________
Applicant/Licensee:
I request that the information in my NABP e-Profile be changed as I indicated on this form. I affirm that the
information provided on this form, and submitted in connection with this form, is true, correct, and complete. I
understand that if false or misleading information is provided in, or in connection with, this form, NABP may elect to
pursue any and all available remedies including, but not limited to, suspension or termination of my NABP e-Profile
ID or referral of the matter to regulatory, government, or law enforcement authorities.
Notary:
State of ________________________________ County of ________________________________________
I certify that on __________ (day) of _____________ (month), ______________________________ (year),
_________________________________________ (name of affiant) personally appeared before me, and is
personally known to me or proved to me on the basis of a current official federal or state government photo
identification to be the individual whose name is subscribed on this form and acknowledged to me that he/she has
executed this form and swore that the statements made by him/her on this form are true, correct, and complete and
all supporting documents in connection with this form are true, correct, and exact copies of the official record
maintained by the designated governmental body.
Notary Public signature _______________________________________
Notary Stamp
Notary ID number ____________________________________________
Expiration date _________/__________/__________
Month
Day
Year
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