Name Change Request Form - Louisiana State Board Of Nursing
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1Louisiana State Board of Nursing
17373 Perkins Road, Baton Rouge, LA 70810
Telephone: (225) 755-7500 Credentialing Dept Fax: (225) 755-7581
NAME CHANGE REQUEST FORM
I am requesting the Louisiana State Board of Nursing adjust my licensure record to reflect the
following name change. I am submitting along with this form the following Board required
documentation to process my request:
(check one box and attach/submit with this completed form)
- photocopy of official certificate of marriage
- photocopy of court documents indicating finalized divorce / divorce decree
- photocopy of court documents indicating a legal name change
RN/APRN License #: _________________________ Social Security #: _____________________________
New Name: _______________________________________________________________________________
Previous Licensed Name: ___________________________________________________________________
Mailing Address: _________________________________________________________________________
- check if new address
_________________________________________________________________________
Home Phone: (______)_____________________
Work Phone: (______) __________________________
Cell Phone : (______)_____________________
Email: _______________________________________
Identifying Information :
Date of Birth: ____________________ City & State of Birth: ___________________________________
School of Nursing: _________________________________________ Year Graduated: ______________
City/State school of nursing was located: ____________________________________________________
________________________________________
Signature of nurse
date signed
Mailing address changes are posted by the nurse electronically at the LSBN website
under My Services / Address Change. Updating an email address and/or
phone number(s) are posted by the nurse online under My Services / My Profile. Verification of
licensure status and name change can be viewed under Licensure Verification on the LSBN
homepage. Please allow ten (10) business days after receipt of your name change request to LSBN for
processing.
** All changes in contact information should be updated/reported within 30 days **
LSBN Name Change form – 4/08, 6/10, 1/12, 7/12
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