Arizona State Board Of Nursing Name Change/duplicate License/certificate Request
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1For office use only
Arizona State Board of Nursing
th
4747 N. 7
Street, Suite 200, Phoenix, AZ 85014-3655
Phone (602) 771-7800
E-Mail: arizona@azbn.gov
Home Page:
Name Change/Duplicate License/Certificate Request
Applicant Information:
Name (please print):_____________________________________________________
Social Security #: _______-_____-________ Email: _________________________
Phone Number: (_____) ______-______ Cell Phone Number: (_____) _____-______
RN
LPN
ADVANCED PRACTICE
CRNA
SCHOOL NURSE
CNA
Check all that apply:
Name Change Request
Duplicate License/Certificate Request
CNA Original Document Request
NAME CHANGE
Pursuant to the Nurse Practice Act (R4-19-308 and R4-19-812), a licensee, applicant or a certified nursing assistant who legally
changes names must notify the Board in writing within 30 days of any name change. The applicant shall submit a copy of any
official document evidencing the name change. DO NOT SEND YOUR ORIGINAL DOCUMENTS.
Must provide documentation to verify license/certificate holder’s previous name (i.e. birth certificate, a social security card,
marriage license, divorce decree, High School diploma) and documentation which verifies the licensee/certificate holder’s
current name (i.e. divorce decree, driver’s license, social security card, marriage license).
Former Legal Name: ___________________________________________________________________________________
Last
First
Middle Name or Initial
New Legal Name:
___________________________________________________________________________________
Last
First
Middle Name or Initial
DOCUMENT REQUEST
ORIGINAL DOCUMENT (CNA only):
Original CNA Document (Exam/Renewal) $50
DUPLICATE DOCUMENT: (select the license or certificate that pertains to you)
RN/LPN LICENSE $25
ADVANCED PRACTICE/CRNA/SCHOOL NURSE $25
CNA $25 (Only if an original CNA document has previously been paid for and received.)
Reason for Duplicate : (Only check one box)
Card Lost/Stolen: Include a statement to explain the circumstances surrounding loss of license or certificate.
Statement of loss: ___________________________________________________________________________________
___________________________________________________________________________________________________
Name Change (If requesting a new license/certificate reflecting the new name.)
Name and Address change (If requesting to change your address in addition to changes/requests made on this form,
complete the Declaration of Primary State of Residence/Change of Address form and submit both forms/payments
together.)
ALL PERSONAL CHECKS MUST BE PRE-PRINTED WITH YOUR NAME AND ADDRESS AND MADE PAYABLE TO THE ASBN
The undersigned verifies that he/she is the person referred to on this request form, and that the statements are true in every
respect.
FEES ARE NOT
__________________________________________
_______________________
REFUNDABLE
Signature
Date
N:\APPLICATIONS\Web Applications Current\Web Forms\Duplicate Request_Name Change_ 2013.doc
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