Free 45180.FH11 - Indiana

REQUEST FOR CHANGE OF NAME, ADDRESS OR DUPLICATE LICENSE
State Form 45180 (R4 / 4-03) Approved by State Board of Accounts, 2003 Check applicable request(s):

Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, Indiana 46204 317-232-2980 www.in.gov/pla

Name change
Social Security number*

Address change

Duplicate pocket card

Duplicate wall certificate

LICENSEE INFORMATION * This agency is requesting the disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure is mandatory; this record cannot be processed without it.
License number (alpha letters, numbers) Type of license you hold

Current name (please print or type) (indicate new name for name change) Current address (number and street) (indicate new address for address change) City, state, ZIP code

NAME CHANGE
Previous name (please print or type) Please attach copies of legal proof of the name change

DUPLICATE POCKET LICENSE
Required fees: (no fee for license types not indicated here)

$5.00 for Auctioneer

$10.00 for Appraiser, Barber, Cosmetology Professionals, Funeral and Cemetery, Land Surveyor, Professional Engineer DUPLICATE WALL CERTIFICATE

Please note: Wall certificates are not issued for Barbers and Cosmetology Professionals. Required fees: (no fee for license types not indicated here)

$5.00 for Auctioneer

$10.00 for Appraiser, Architect, Funeral and Cemetery, Professional Engineer Destroyed

$25.00 Land Surveyor

Check reason for duplicate pocket / wall certificate: Signature of licensee

Lost I hereby certify that the above information is true and correct.

Nonreceipt of original document
Date signed (month, day, year)