Application For Name Change/duplicate Copy Of Certificate Form
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1A
PPLICATION FOR
N
C
D
C
C
AME
HANGE OR
UPLICATE
OPY OF
ERTIFICATE
– C
A
D
E
U
RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: (602) 542-4367
GENERAL INSTRUCTIONS AND INFORMATION:
Please submit the following:
Step 1: Complete this application, sign and date.
Step 2: Mail the following to: ADE - Certification Unit, P.O. Box 6490, Phoenix, AZ 85005-6490:
Checklist:
Completed application, signed and dated.
$20 personal check, money order or cashier’s check made payable to the
“Arizona Department of Education”. Fees are not refundable. Cash will not be accepted.
If applying for a name change, proof of name change must be included, see below. Photocopies accepted.
Step 3: The Certification Unit will review your application for completeness, correct fee and proof of name change (if
applicable). Once verified, a new printed certificate will be mailed to the address below.
SECTION 1: PERSONAL INFORMATION (TYPE OR PRINT IN BLUE OR BLACK INK)
Social Security Number:
________-_______-__________
Date of Birth:
_____/_____/________
Gender: M/F
(For identification purposes only)
Full Legal Name:
________________________________________________________________________________________________
Last
First
Middle
Mailing Address:
________________________________________________________________________________________________
Street Number or P.O. Box
City
State
Zip
Telephone:
(______) ______-________
Email Address:
_________________________________________
____ Asian or Pacific Islander
____Black or African-American (Not-Hispanic)
____Hispanic or Latino
Ethnicity:
____ White (Not-Hispanic)
____American Indian or Alaskan Native
____Other
(Gender and Ethnicity are requested for federal reporting purposes only)
SECTION 2: SERVICE(S) REQUESTED
PLEASE PLACE AN “X” ON THE LINE NEXT TO THE REQUESTED SERVICE, SIGN AND DATE
____
A duplicate copy of my certificate.
____
A name change of my educator file due to my name being legally changed.
Submit proof of name change. Acceptable forms of proof include: Marriage License, Driver’s License, Court
Order or Divorce Decree. Photocopies accepted.
FORMER NAME: ________________________________________________________________________________
Last
First
Middle
NEW NAME: ________________________________________________________________________________
Last
First
Middle
_______________________________________________________________
_________________
Applicant’s Signature
Date
** R
A
R
S
A
C
. **
EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE
RIZONA
EVISED
TATUTES AND
DMINISTRATIVE
ODE
Version 3.1 (Revised 2-5-2013)
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ERTIFICATION
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