Address/Name Change - Professional Licensing Boards

WYOMING BOARD OF VETERINARY MEDICINE
Address/Name Change Form
1. Old Name and/or Mailing Address
Last Name
First Name
Old Address
City
(
Middle Initial
State
Zip Code
)
Phone Number
License/Certificate Number
2. New Name and/or Mailing Address
A copy of the following documentation must accompany a name change request: marriage license, divorce decree (only the page
showing the name change) or court order. Send a copy only. Originals will not be returned.
Last Name
First Name
New Home Address
City
(
Middle Initial
State
Zip Code
State
Zip Code
)
Phone Number
E-mail Address
New Business Name
New Business Address
(
)
City
I prefer to receive mail at my
Home
Business (Check One)
Phone Number
3. Replacement Certificate/Pocket Card for Name Change
Replacement fee: $25.00
Fees are payable by personal check, cashier’s check or money order only, made payable to the State of Wyoming.
4. Affidavit
I am the person making the foregoing statements and that they are made in good faith and are true in every respect. I have read,
understand, and agree to abide by the Rules and Regulations promulgated by the Board of Veterinary Medicine, and W.S. § 3330-101 through 225.
Signature
Date
For questions or further instruction, contact Rick Bengston at [email protected] or (307) 777-5403. Mail this form and
required fees: Wyoming Board of Veterinary Medicine, Emerson Bldg., RM 104, 2001 Capitol Ave, Cheyenne, WY 82002