Name And Address Change Form
ADVERTISEMENT
1
2THIS FORM IS TO BE USED FOR NAME AND ADDRESS CHANGE
AND Order Form for Replacement Certificate
Complete and Mail to:
Ohio Respiratory Care Board
th
77 South High Street, 16
Floor
Columbus, OH 43215-6108
614-752-9218
Instructions:
1)
Please complete Sections A and B for name and address changes. Complete Section A and C if you are
requesting a replacement certificate. Print or Type ONLY.
2)
The affidavit on page 2 MUST be notarized. To change a name, you must present to the notary and send a
copy of one of the following documents along with this form to the address listed above:
Marriage certificate/abstract
Divorce decree
Court record indicating name change
Documentation from another state/country consistent with the laws of that jurisdiction reflecting the name
change.
3)
Cost for Wall Certificate is $10.00.
4)
Make checks Payable to: TREASURER, STATE OF OHIO.
Section A
Last Name
First Name
MI
Former Name
Street Address
Address
City
State
Zip Code
County
Employer
Street Address
City
State
Zip Code
County
Section B
Last Name
First Name
MI
New Name
Street Address
New Address
City
State
Zip Code
County
Employer
Street Address
City
State
Zip Code
County
Section C
License Number
Name (First, MI, Last)
$10.00 Certificate
Home Phone Number
Work Phone Number
Reason for Replacement (lost, destroyed, or stolen)
RCB 017 (3/03) Revised 12/2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal