Name Change

West Virginia Board of Examiners
for Registered Professional Nurses
101 Dee Drive, Suite 102
Charleston, WV 25311-1620
Phone: (304) 558-3596
Fax: (304) 558-3666
Email: rnboard@wv.gov

Name Change Form:
(printable) Non-refundable Fee: Name Change and New License = $10.00 Must return current permanent license or a lost license form notarized with this application

Name
Address
License #		Soc. Sec. #

AFFIDAVIT

STATE OF _________________________

COUNTY OF ________________________

I, __________________ , formerly the undersigned __________________ , being duly sworn according to law, do depose that on the day of __________________ , 20___ , I was married/divorced to/from (spouse) __________________ , in County __________________ , State __________________ and that my name has been changed from (former name) __________________ , to (current legal name) __________________ .

Signature of Affiant ________________________________

Subscribed and sworn to before me this ________________ day of __________________ , 20___.

My commission expires on the ________________ day of __________________ , 20___.

(SEAL)

Notary Public in and for

COUNTY ________________________

STATE _________________________

______________________________________________________

NOTARY SIGNATURE

IN ADDITION IF YOU WANT A REPLACEMENT LICENSE TO REFLECT THESE CHANGES YOU MUST RETURN YOUR CURRENT LICENSE TO THE BOARD WITH AN ADDITIONAL FEE OF $5.00.

TO CHANGE RECORDS THERE IS A FEE OF:

$5.00 .............FOR NAME CHANGE

$10.00...........FOR NAME CHANGE and REPLACEMENT LICENSE

REV:4/06

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