North Carolina Psychology Board Name Change Form
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1NORTH CAROLINA PSYCHOLOGY BOARD
NAME CHANGE FORM
You may email, mail or fax this form to the North Carolina Psychology Board. Please attach one
copy of the legal documentation (marriage cert., drivers license, divorce paper decree, etc.).
COMPLETE AND EMAIL OR MAIL THIS FORM TO:
Email:
Mail: NC Psychology Board
895 State Farm Rd., Suite 101
Boone, NC 28607
Please provide the information below:
1. Previous name: ______________________________________________________________________
2. New name: _________________________________________________________________________
(First)
(Middle)
(Last)
3. License number: _____________________________________________________________________
4. Current email address: _______________________________________________________________
Please attach one copy of the legal documentation (marriage cert., drivers license, divorce
paper decree, etc.).
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