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Nabp.net E-mail custserv nabp.net Name Change Granted by a US Government Agency Complete and hand sign this form in front of a notary and make a copy for your file. National Association of Boards of Pharmacy 1600 Feehanville Drive Mount Prospect IL 60056-6014 Tel 847/391-4406 Fax 847/375-1114 Web Site www. Please type or print legibly. Mail or fax this signed and notarized original form with a photocopy of your name change documentation marriage license/certificate divorce decree or court ordered name change document to NABP Customer Service at the address above. Your Current Name Date of Birth Your Signature NABP e-Profile ID if applicable Pharmacist/Technician License No State if applicable Mailing Address Phone Number E-mail Address Former Name New Name Reason for Change Applicant/Licensee I request that the information in my NABP e-Profile be changed as I indicated on this form* I affirm that the information provided on this form and submitted in connection with this form is true correct and complete. I understand that if false or misleading information is provided in or in connection with this form NABP may elect to pursue any and all available remedies including but not limited to suspension or termination of my NABP e-Profile ID or referral of the matter to regulatory government or law enforcement authorities. Notary State of County of I certify that on day of month year name of affiant personally appeared before me and is personally known to me or proved to me on the basis of a current official federal or state government photo identification to be the individual whose name is subscribed on this form and acknowledged to me that he/she has executed this form and swore that the statements made by him/her on this form are true correct and complete and all supporting documents in connection with this form are true correct and exact copies of the official record maintained by the designated governmental body. Please type or print legibly. Mail or fax this signed and notarized original form with a photocopy of your name change documentation marriage license/certificate divorce decree or court ordered name change document to NABP Customer Service at the address above. Your Current Name Date of Birth Your Signature NABP e-Profile ID if applicable Pharmacist/Technician License No State if applicable Mailing Address Phone Number E-mail Address Former Name New Name Reason for Change Applicant/Licensee I request that the information in my NABP e-Profile be changed as I indicated on this form* I affirm that the information provided on this form and submitted in connection with this form is true correct and complete. Your Current Name Date of Birth Your Signature NABP e-Profile ID if applicable Pharmacist/Technician License No State if applicable Mailing Address Phone Number E-mail Address Former Name New Name Reason for Change Applicant/Licensee I request that the information in my NABP e-Profile be changed as I indicated on this form* I affirm that the information provided on this form and submitted in connection with this form is true correct and complete. I understand that if false or misleading information is provided in or in connection with this form NABP may elect to pursue any and all available remedies including but not limited to suspension or termination of my NABP e-Profile ID or referral of the matter to regulatory government or law enforcement authorities.