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
Name Change Form:
Non-refundable Fee: Name Change and New License = $10.00
Must return current permanent license
or a lost license form notarized with this application
||Soc. Sec. #
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___.
Notary Public in and for
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