Form Bol-Naca - License Name And/or Address Change Affidavit printable pdf download

Form Bol-Naca - License Name And/or Address Change Affidavit

BUREAU USE ONLY

BUREAU OF OCCUPATIONAL LICENSES

Receipt #

__________

1109 Main St., Suite 220

Boise, Idaho 83702-5642

Date Rec’d __________

(208) 334-3233

Date Chg’d __________

LICENSE NAME AND/OR ADDRESS CHANGE AFFIDAVIT

INSTRUCTIONS

This completed affidavit must be submitted to the Bureau of Occupational Licenses. All changes requested will

appear on your next license. If your license has been issued and you wish to receive a new license bearing the

requested change(s), you are required to return this form with your current license(s) and a $10.00 fee.

I _____________________________________________________, affirm that I am the legal and lawful

Print or type full name of licensee

owner of license, certificate, or permit number______________ and hereby request a change or correction in

complete license number

the official public record. Please change my [ ] Name and/or [ ] Address as noted below.

My name (print/type) exactly as it appears on my license:

________________________________________

My name (print/type) exactly as I wish it to appear:

________________________________________

I am enclosing as authorization for said change, a copy of (one of the following):

[ ] Marriage License [ ] Divorce Decree [ ] Court document noting change

[ ] Social Security card [ ] Birth Certificate

NOTE: A social security card or birth certificate is acceptable for spelling corrections only.

My address (print/type) exactly as it appears on my license: ________________________________________

________________________________________

My address (print/type) exactly as I wish it to appear:

________________________________________

(This is a Public Record address. If you wish to

________________________________________

change your mailing address only, please check

this box [ ] and enter your mailing address here.

________________________________________

Your license will still bear the address currently

appearing on your license.)

__________________________________________

Signature of Applicant

_____________________

Date

BOL-NACA-09/00

Form Bol-Naca - License Name And/or Address Change Affidavit