Arkansas Name Change Request Form PDF Details

In the professional journey of a nurse in Arkansas, circumstances such as marriage, divorce, or other personal decisions may necessitate a change of name. Recognizing the importance of accurate and consistent identification across all professional documents, the Arkansas State Board of Nursing provides a Name Change Request form. This document, essential for maintaining the integrity of a nurse's licensure and official records, outlines a clear procedure for updating one's name. With a fee of $30 for each license affected by the name change, the form also stresses the critical nature of truthfulness, warning that falsification can lead to disciplinary action against one's license. It instructs nurses on how to submit evidence of their name change—via marriage license, divorce decree, or court action—and requires the indication of the nurse's primary state of residence in line with the Nurse Licensure Compact. Although a new license is not issued upon a name change, the modification is recorded and filed by the ASBN, ensuring that all nursing documentation reflects the current legal name. Payment methods are accommodated with options including personal check, money order, cashier's check, or credit card, with an additional nominal processing fee for card transactions. This procedure not only guarantees legal compliance and professional coherence but also provides a seamless transition for nurses undergoing significant personal life changes.

QuestionAnswer
Form NameArkansas Name Change Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesName Change Request Form how to notify the arkansas state board of nursing of a name change form

Form Preview Example

FOR OFFICE USE ONLY

FALSIFICATION OF THIS FORM IS GROUNDS FOR DISCIPLINARY ACTION AGAINST YOUR LICENSE.

ARKANSAS STATE BOARD OF NURSING

UNIVERSITY TOWER BUILDING

1123 SOUTH UNIVERSITY, SUITE 800 LITTLE ROCK, ARKANSAS 72204

501.686.2700 • 501.686.2714 fax • www.arsbn.org •

NAME CHANGE REQUEST

Your nursing documentation should be signed with the name that is on file with ASBN.

NAME CHANGE AND LICENSE REQUEST - $30.00 FOR EACH LICENSE.

NAME CHANGE REQUEST - NO FEE Note: You will not receive a replacement license, but your name change will be on file with ASBN.

This is to certify that my name has been legally changed from:

FIRSTMIDDLEMAIDENLAST

to

 

FIRST

 

 

MIDDLE

 

 

 

 

 

 

LAST

due to

Marriage

Divorce

Religious Order

Other

 

 

 

 

 

Such as recorded in

 

 

 

County, State of

 

 

 

 

 

 

Social Security Number

 

 

 

Telephone Number (

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME

 

WORK

 

License Number

Current Address

E-mail address

 

 

Date of Birth

Date of Legal Name Change

 

 

 

 

MM/DD/YYYY

 

MM/DD/YYYY

 

 

 

 

 

 

 

STREET/P.O. BOX

 

CITY

STATE

ZIP

Name Change for:

Legal Document Submitted

check type of license(s)

(check one)

RN

Marriage license

 

LPN

Divorce decree

Court action

 

LPTN

Attach a copy (front and

 

APRN

back) of the marriage

RNP

license, divorce decree or

court action showing your

 

newly changed name.

Declaration of primary state of residence:

In accordance with A.C.A. §17-87-601 (Nurse Licensure Compact), I

declare the State of __________________ as my primary state of resi-

dence and that such constitutes my permanent and principal home for legal purposes.

Signature

Date

Replacement License Fee

$30.00 per license

METHOD OF PAYMENT

In-state personal check

Money order/cashiers check

Credit card

FEES ARE NONREFUNDABLE

CREDIT CARD INFORMATION

Complete below if paying by credit card. There is a nominal processing fee (listed below) assessed with paying your fees by credit card. The Arkansas State Board of Nursing does not receive any portion of the processing fee.

 

Type of card

Visa

 

MasterCard

Discover

 

Cardholder’s Name

 

 

 

 

 

 

 

 

 

 

Cardholder’s billing address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip

 

 

 

Credit Card #

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration date

 

 

 

/

 

 

Amount Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mm

 

yyyy

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

*Processing fee - Replacement license- $0.90

 

 

 

 

7.16 lw

 

 

 

 

 

 

 

 

 

 

 

0018

 

 

 

 

 

 

 

 

 

 

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Arkansas Name Change Request Form conclusion process shown (stage 1)

2. When the prior section is completed, proceed to enter the relevant details in all these - LPTN, APRN, RNP, Divorce decree Court action, Attach a copy front and back of, license divorce decree or court, newly changed name, In accordance with ACA Nurse, Signature, Date, Replacement License Fee per, METHOD OF PAYMENT, Instate personal check, Money ordercashiers check, and Credit card.

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