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