The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Name Change Form
DO NOT USE THIS FORM IF YOU NEED TO CHANGE YOUR ADDRESS ONLY. TO ONLY CHANGE YOUR ADDRESS, SUBMIT A
CONTACT US FORM AT https://eservices.nysed.gov/professions/contact-us/#/
Instructions: Use this form to report a change in your name. Read these instructions carefully and complete all applicable sections of this
form. Be sure to print clearly in ink.
You must include acceptable supporting documentation from one of the options listed below. DO NOT send original documents,
ONLY submit copies of supporting documentation. Acceptable supporting documentation includes:
Option One:
●
A copy of one (1) of the following documents authorizing your name change: a court order, marriage certificate, divorce papers,
amended birth certificate or naturalization papers authorizing your name change, AND
●
A copy of a government issued photo ID in your new name.
●
A letter from the Social Security Administration indicating both your old and new names.
●
Copies of both old and new driver's licenses.
●
Copies of both old and new New York State non-driver photo ID cards.
●
Copies of both old and new Social Security Cards.
●
Copies of both old and new passports.
●
Copies of both old and new U.S. Military photo ID cards.
Option Two (You will need two (2) of the following sets of supporting documentation):
Be sure to sign and date the affidavit in Section IV before submitting the completed form along with copies of any required
documentation to the Office of the Professions at the address at the end of the form.
FAILURE TO COMPLETE ALL REQUIRED PARTS OF THIS FORM AND/OR INCLUDE ANY COPIES OF REQUIRED DOCUMENTATION
WILL DELAY ITS PROCESSING.
Licensed professionals can check the Office of the Professions' web site at www.op.nysed.gov
to verify your name, city, state, registration
expiration date, and license number on record.
NOTE: Important information and registration renewals will be sent to the address on file for you. You must notify the Department in writing
within 30 days if your address or name changes.
Section I - General Information
1. Your Name Currently on Record:
2. Social Security Number
3. Birth Date
Month Day Year
4. Contact Information
Telephone Number
Home Business
Current Email
Home Business
Licensee business phone and email address are
public information. Failure to indicate business or
home on this form for each item will deem it public
information.
5. Effective date of change
(Note: Changes cannot be accepted until after the effective date)
6. I am (check one):
For/In the profession* of
*For a list of professional titles licensed under Education Law, visit the Office of the Professions' website at www.op.nysed.gov
.
an applicant for licensure in New York State
currently licensed in New York State
If you are currently licensed, enter your New York State license number
Name Change Form, Page 1 of 2, Rev. 4/24
Section II - Updated Information
OLD Name Currently on Record
Last Name
First Name
Middle Name or Initial
NEW Name You are Changing to
Last Name
First Name
Middle Name or Initial
Complete only if Applicable:
Is this new address a
Home address, or Business address
Licensee business addresses are public information. Failure to indicate if the new address is business or home will deem it public information.
OLD Address Currently on Record
Apartment/Building
Street
City
State
ZIP Code
Province or Country (If not U.S.)
NEW Address You are Changing to
Apartment/Building
Street
City
State
ZIP Code
Province or Country (If not U.S.)
Section III - Replacement Documents for Licensees
Licensed professionals who are currently registered will be sent an updated registration certificate in their NEW name. Also, if you would like to
replace your existing license parchment with one in your NEW name, check below AND enclose a $10 check or money order made payable
to the New York Education Department. If possible, you must also return your old parchment to the Office of the Professions at the address
at the end of the form or attest to its destruction.
I am requesting an updated license parchment in my NEW name.
Also, I attest that my original license parchment (check one):
will be mailed back to the Office of the Professions.
is lost.
is stolen.
will be, or already is shredded/destroyed.
Example License Parchment
Section IV - Affidavit
I declare and affirm that the statements above are true, complete, and correct. I understand that any false or misleading information in, or in
connection with, my application or this notification may be cause for denial or loss of licensure and may result in criminal prosecution.
Signature Date
Submission of this Form for Applicants for New York State Licensure
Mail this form to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
* Unit, 89 Washington Avenue, Albany, NY 12234-1000.
OR, You can submit this form and copies of any required documentation to the Office of Professions directly on our website
. You will need
your Application ID and Birth Date.
*For a list of professional titles licensed under Education Law, visit the Office of the Professions' website at www.op.nysed.gov
.
Submission of this Form for Licensed Professionals
Mail this form and fee to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Records and Archives Unit, 89 Washington Avenue, Albany, NY 12234-1000.
OR, You can submit this form and copies of any required documentation by email to
Name Change Form, Page 2 of 2, Rev. 4/24
