Name / Address / Employer Change Request Form For Individual Licensees - Minnesota Board Of Accountancy

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CLEAR
CLEAR
M
B
a
Ph: 651-296-7938
innesota
oard of
ccountancy
FORM
FORM
Fax: 651-282-2644
85 East 7th Place, Suite 125
boa.state.mn.us
St. Paul, MN 55101-2143
NAME / ADDRESS / EMPLOYER CHANGE REQUEST FORM
FOR INDIVIDUAL LICENSEES
Mail or fax this form to the Board office.
The following information has changed:
Address
Name
Employer
Preferred “mail to”:
Name
Home
Business
(First)
(M.I.)
(Last)
(Suffix)
Former Name
Employer Name
(If applicable. See note below regarding required documentation.)
Certificate #
Work Phone
Home Phone
Work Fax
Work Address
Home Address
Work City
City
State
Work State
Work Zip
Zip
Signature
Date
Name changes:
You must include a copy of your legal name change
documentation, such as a marriage certificate, pertinent section of
divorce decree, etc. Name changes cannot be made without legal documentation.
Firms:
Do not use this form.
Use the
Firm Name Change Form
appropriate to your type of firm:
boa.state.mn.us/forms.html
Rev 02/17
Change of Name / Address / Employer Form—Page 1 of 1

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