The Arkansas Name Change Request form is a document used by individuals to officially update their name with the Arkansas State Board of Nursing (ASBN). This form is essential for nurses who have legally changed their name due to marriage, divorce, or other reasons. By submitting this form, individuals ensure that their nursing documentation reflects their current legal name.
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When filling out the Arkansas Name Change Request form, it’s important to follow certain guidelines to ensure a smooth process. Here are five things you should and shouldn’t do:
The Arkansas Name Change Request form is used by individuals who wish to update their name on file with the Arkansas State Board of Nursing (ASBN). This form is particularly important for nurses who have legally changed their name due to marriage, divorce, or other reasons. While there is no fee for submitting the name change request, it is essential to ensure that your nursing documentation reflects your current legal name for accurate record-keeping and identification purposes.
There is no fee for submitting the Name Change Request form itself. However, if you are also requesting a replacement license that reflects your new name, there is a fee of $30.00 for each license. It is important to note that while your name change will be recorded with the ASBN, you will not receive a new license unless you specifically request one and pay the associated fee.
When submitting your Name Change Request, you must include a copy of the legal document that supports your name change. This could be a marriage license, divorce decree, or court action documentation. Make sure to provide copies of the relevant documents, as they will be necessary for processing your request. It is also important to ensure that your current address, phone number, and email are up-to-date on the form.
You can submit the Name Change Request form by mailing it to the Arkansas State Board of Nursing at their office address: University Tower Building, 1123 South University, Suite 800, Little Rock, Arkansas 72204. Alternatively, you can also fax the completed form to 501.686.2714. If you are paying by credit card for a replacement license, be sure to include your credit card information on the form. Remember to keep a copy of your submission for your records.
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
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
*Processing fee - Replacement license- $0.90
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