Social Work Name/address Change Form
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1COMMONWEALTH OF VIRGINIA
BOARD OF SOCIAL WORK
Department of Health Professions
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233-1463
(804) 367-4441
Article I.
Website -
SOCIAL WORK NAME/ADDRESS CHANGE FORM
All name/address changes are completed in the order received. Please allow approximately 5-7 business days for processing. You will
receive written notification through the mail when the name/address change is completed. The address/name change may be faxed or
mailed to the board office.
If you wish to receive a license with this change prior to the next renewal, please mail this form with a check or money order in
the amount of $15.00. The check or money order should be made payable to the “Treasurer of Virginia.”
CURRENT INFORMATION:
Last Name
First Name
M.I.
Maiden or Other
Social Work License Number
Last four digits of your Social Security Number
XXX-XX- ____ ____ ____ ____
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;
3.) Other legal document indicating the retaking of
2.) Divorce decree which indicates the retaking of
your maiden name;
your maiden name;
4.) Copy of court documents.
NEW NAME:
Last
First
Middle
CHANGE OF ADDRESS
OLD ADDRESS:
Street Address
City
State
Zip
NEW ADDRESS:
Street Address
City
State
Zip
Should this new address be used as both your public and
If not, please provide a public address to add to our records:
private address?
Business Name: __________________________________________________
Street Address: ___________________________________________________
City: ___________________________________________________________
YES
NO
State: ___________________________________________________________
Zip: ____________________________________________________________
SIGNATURE OF LICENSEE _____________________________________________________ DATE ________________________
Revised 12/2015 – Name/Address Change Form
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Parent category: Legal