Arkansas Name Change Request Form – Fill Out and Use This PDF

The Arkansas Name Change Request form is a document from the Arkansas State Board of Nursing (ASBN) for nurses who need to update their professional credentials after marriage, divorce, or a court order. To submit your name change petition, attach supporting documents such as a marriage certificate or divorce decree, and include the $30 fee per affected license. The ASBN records the updated name in your nursing file without issuing a new credential. Click the button below to fill out and sign the PDF online.

Get Form Now Download PDF

Arkansas Name Change Request Form PDF Details

Arkansas nurses may need to update their legal name due to marriage, divorce, or a court order issued by a circuit court. The Arkansas State Board of Nursing (ASBN) requires a completed name change petition along with supporting documents such as a marriage certificate, a divorce decree, or a court order signed by a judge. The petition must list your current license number and the newly changed name.

Filing costs $30 per affected nursing credential. Accepted payment methods include:

Personal check or money order

Cashier's check

Credit card (small processing fee applies)

No new credential is issued. The change is entered into your ASBN case file and all official records are updated. Per the Nurse Licensure Compact, indicate your primary state of residence on the filing.

Nurses holding both an RN and LPTN must file a separate petition and pay the fee for each credential affected. Falsification of information can lead to disciplinary action. All supporting documents must be originals or certified copies. Mail your completed petition and payment to the ASBN in Little Rock, Arkansas. For related documents, see the petition for name change, the divorce decree, or the court name change process.

Question	Answer
Form Name	Arkansas Name Change Request Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Name Change Request Form how to notify the arkansas state board of nursing of a name change form

How to Edit Arkansas Name Change Request Form Online for Free

Editing PDF documents online is straightforward with our PDF editor. Anyone can complete the Arkansas Name Change Request form here in minutes. Our team continuously improves the tool to make it faster and more useful. All your data is handled securely and stays private throughout the process. With just a few basic steps, you can begin your PDF editing:

Step 1

Click the "Get Form Button" at the top of this page to open our PDF editor. There you will find all the tools needed to work with this document.

Step 2

The tool allows you to modify the PDF in a variety of ways. Add personalized text, adjust existing entries in the document, and include a signature when you need it.

This document requires specific details to be entered in each section, so take the time to fill in everything carefully:

1. To get started, fill in the area shown below:

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

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

Stage no. 2 in filling in Arkansas Name Change Request Form

People who use this PDF often make mistakes when entering the license and divorce decree fields. Double-check everything in those sections before submitting. Ensure all document fields are complete and legible before submitting. For related filings, see the address name change form or the Kentucky name change petition.

Step 3

After reviewing all your entries, click "Done" to finish. With a 7-day free trial, you can save and access the completed document at any time from your personal account page. Download or share a copy for your records. We do not share or sell any information you provide while completing documents on our site.