Fillable "Duplicate License" Or "Amended (Name Change) License" Request Form & Affidavit

Texas State Board of Podiatric Medical Examiners

P.O. Box 12216, Austin, TX 78711-2216

333 Guadalupe, Suite #2-320, Austin, TX 78701

MAILING ADDRESS:

PHYSICAL ADDRESS:

512.305.7000

512.305.7003

TELEPHONE:

FAX:

WEBSITE ADDRESS:

TSBPME

“DUPLICATE LICENSE” OR “AMENDED (NAME CHANGE) LICENSE”

REQUEST FORM & AFFIDAVIT

Agency Use Only:

Processed By: _____________; Date Database Updated: _____________; Cost: _____________; Check No.: _____________

Instructions:

1) Print in black/blue ink or type.

2) Fill out form completely and do not leave any questions blank. If an item is not applicable, mark “N/A.”

3) Podiatric Physicians / License Holders requesting a “Duplicate License” or an “Amended License” (“Name Change”) are

REQUIRED to submit a copy of legal documentation evidencing the request/change, i.e. copy of a marriage license, divorce decree,

court order, affidavit, etc. and the original TSBPME license. (Note: The original Texas Podiatry License reflects the signatures of all

Board Members and MUST be returned before a new license is issued. The new “Duplicate License” or “Amended License” will be

issued upon receipt of all required items.)

4) This form MUST be completed (signed/dated) by the Podiatric Physician / License Holder and MUST be notarized.

5) Submit this completed Form along with All Documentation to the Mailing Address above along with the $50.00 (non-refundable)

Fee payable to the “TSBPME.” Payment can be made by check, money order or cashier’s check (do not send cash).

Statutory Reference:

Texas Occupations Code §202.263 “ISSUANCE OF DUPLICATE OR AMENDED LICENSE” provides that: “(a) If a license issued

by the Board is lost, destroyed, or stolen from the person to whom it was issued, the license holder shall report the fact to the Board in

an affidavit. The affidavit must include detailed information as to the loss, destruction, or theft, giving dates, place, and circumstances.

(b) A license holder may apply to the Board for an amended license because of a lawful change in the person's name or degree

designation or for any other lawful and sufficient reason. The license holder must state the reasons that the issuance of an amended

license is requested. (c) The Board shall issue a duplicate or amended license on application by a license holder and payment of a fee

set by the Board for the duplicate or amended license. The Board may not issue a duplicate or amended license unless: (1) the license

holder submits sufficient evidence to prove the license has been lost, destroyed, or stolen or establishes the lawful reason that an

amended license should be issued; and (2) the Board's records show a license had been issued and was in effect at the time of the loss,

destruction, or theft or on the date of the request for an amended license. (d) If an amended license is issued, the license holder shall

return the original license to the Board.”

Podiatric Physician Name (as it appears/appeared on the issued “Original License”):

____________________________________________________________________________________________________________

Texas License Number: ____________________

3. Date Issued: ____________________

I am requesting (√ one box only):

“Duplicate License” (due to loss/destruction/theft)

“Amended License” (due to lawful name change)

"Duplicate License" Or "Amended (Name Change) License" Request Form & Affidavit - 2013

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