The Arkansas Name Change Request form is a document used by individuals seeking to officially update their name with the Arkansas State Board of Nursing. This form is essential for maintaining accurate nursing documentation and ensuring that all records reflect the individual's current legal name. To initiate the process, complete the form and submit it by clicking the button below.
Changing your name can be a significant step in personal and professional life, especially for nursing professionals in Arkansas. The Arkansas Name Change Request form serves as a vital tool for individuals seeking to update their name on file with the Arkansas State Board of Nursing (ASBN). This straightforward form requires essential information such as the previous name, the new name, and the reason for the change, whether due to marriage, divorce, or another legal action. Importantly, while there is no fee for the name change request itself, a $30 fee applies if you are also requesting a new license reflecting the name change. It’s crucial to note that although a replacement license will not be issued, the updated name will be recorded with ASBN, ensuring that your nursing documentation aligns with your current identity. Additionally, the form mandates the submission of supporting legal documents, such as a marriage license or divorce decree, to validate the name change. As part of the process, applicants must declare their primary state of residence, which holds significance under the Nurse Licensure Compact. Completing the form accurately and submitting it alongside the required documentation will help ensure a smooth transition in updating your professional 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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