Board Of Registration In Nursing - The Commonwealth Of Massachusetts Department Of Public Health - Division Of Health Professions Licensure
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1The Commonwealth of Massachusetts
Department of Public Health
Division of Health Professions Licensure
239 Causeway Street • Suite 500, 5
Floor • Boston • MA• 02114
th
(617) 973-0900
Board of Registration in Nursing
Use this form to request a name change and/or an address change for an RN, LPN or APRN license. Check all that apply:
NAME CHANGE
ADDRESS CHANGE
Read the following information carefully before completing form:
1.
If you are requesting a name change and you have a current or expired license with another board within the Division, the
requested name change will be effective for all boards.
2.
All addresses are subject to disclosure on request (MGL c. 4, s. 7).
For a name change, you MUST submit photocopies of supporting documents.
Check document submitted:
__marriage certificate
__ divorce decree
__ court documents
License Number: RN ___________ LPN ___________ Expiration Date: _______________________
CNS
APRN category (if applicable, check one):
CRNA
CNM
CNP
PCNS
Social Security Number (Mandatory): _______________________ Date of Birth: ________________
Clearly print or type information as it NOW APPEARS on your
Clearly print or type information as you wish it to appear on your
license:
NEW license:
Name
Name
:______________________________________________
:______________________________________________
Address
Address
: ___________________________________________
: ___________________________________________
City/Town
City/Town
: ________________________________________
: ________________________________________
State
Zip code:
State
Zip code:
: _______________________
___________
: _______________________
___________
Other professional licenses held (check all that apply):
Dentistry
Genetic Counselor
Nursing Home Administrator
Perfusionist
Pharmacy
Physician Assistant
Respiratory Care
My signature hereon attests under penalties of perjury that the information provided is truthful, complete, and for lawful and
honest purposes.
Signature:
________________________________________
For Official Use Only:
MLO Receipt Date:
______________
Daytime Telephone Number
: ______________________
MLO Receipt Number:
______________
Staff Signature:
______________
Date:
_____________________________________________
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