Address Name Change Form – Fill Out and Use This PDF

Oregon State Board of Nursing

Name and/or Address Change Request Form

ATTENTION: There is no fee to submit this request. Use only black or blue ink and print all information legibly. You may fill out this form electronically, then print it out to sign, and either mail, email, or fax to OSBN. Please read Section 2 carefully to ensure you are sending the appropriate documentation with this form to update your records.

Legal Name Change

Section 1: Type of Request- select all that are applicable: Change of Mailing Address

Change to Contact Information (email, phone, etc)

Section 2: Acceptable Types of Documentation

1.Change of Legal Name on Record- Include a copy of your proof of legal name change documentation with this request form. The following types of documentation are acceptable for proof of legal name change:

a.Marriage license or certificate

b.Birth certificate

c.Final divorce decree- provide only the pages indicating the court jurisdiction, stated name restoration (if applicable) and signature of the appointed judge in proceedings.

d.Copy of court records stating legal name change that includes court jurisdiction, previous and new name(s), and signature of authorizing court official.

e.Valid passport

f.A federal or state government-issued photo identification card or driver’s license.

2.Change of Address or Contact Information- Complete Section 3 by providing your updated information, and submit the form to OSBN to process. There is no additional documentation required in order to process this type of request.

NOTE: Per Oregon Administrative Rule, OSBN requires licensees and certificate holders to keep their contact information on file with OSBN current. All correspondence regarding licensure renewal and updates are sent via the email or postal mail address on file that you have provided to OSBN. You may also update your address electronically, by going to the OSBN website at www.oregon.gov/OSBN/ and clicking on “Online Services”.

Section 3: New Contact Information

Date of Birth:	Select the type(s) of		List your Oregon
		CNA/CMA
(mm/dd/yy)	Oregon license/	LPN/RN	license/certificate
	certificate you hold:	APRN	number(s):
Mailing			Country:
Address:			UNITED STATES
US Residents: City:		State/US	Zip
(select from each box)		Jurisdiction:	Code:
Non-US Residents:
(list your city, state/province, and
postal code here)
Primary	Secondary		Email
Phone:	Phone:
Unlisted	Unlisted

I authorize the above information to be used to update my records on file with the Oregon State Board of Nursing.

Signature: _________________________________________ Date (mm/dd/yy): _____________________

Mail or fax your completed form and the required documentation to the contact information below. OSBN will process your request within 10 business days. You may call OSBN at 971-673-0685 with any questions. To view your updated records, go to the OSBN Online Verification System.

Mail, fax, or email form and documentation to:

OSBN‐613 06/01/16