Change Of Address Form - 2003

State of Alaska

Department of Community and Economic Development

Division of Occupational Licensing

P.O. Box 110806

Juneau, AK 99811-0806

E-mail: license@dced.state.ak.us

CHANGE OF ADDRESS FORM

Please complete this form showing your old and new mailing address. You may confirm that

the change has been made to your record by reviewing the division’s website at:

and click on “Occupational License Search.” If you would like a

duplicate license reflecting the change of address, please submit a $5.00 FEE made payable

to the State of Alaska.

LICENSEE’S NAME:

LICENSEE’S PROFESSION:

LICENSE NUMBER:

OLD MAILING ADDRESS:

Name

Address

City, State, ZIP Code

NEW MAILING ADDRESS:

Name

Address

City, State, ZIP Code

Licensee’s Signature

Effective Date

08-4291 (Rev. 7/03)

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Parent category: Legal