The Arkansas Name Change Request form is a document used by individuals seeking to officially update their name on file with the Arkansas State Board of Nursing (ASBN). This form facilitates the process of aligning personal documentation with a new legal name, whether due to marriage, divorce, or other reasons. It is important to note that while there is no fee for submitting a name change request, a replacement license is not issued; instead, the name change is recorded with the ASBN.
The Arkansas Name Change Request form is an essential document for nurses seeking to update their name with the Arkansas State Board of Nursing (ASBN). This form is particularly relevant for those who have experienced a legal name change due to marriage, divorce, or other circumstances. It is important to note that while there is no fee for submitting the name change request, a fee of $30 applies for each license if a name change is accompanied by a license request. The form requires personal details such as the individual's current name, the new name, and relevant documentation to support the name change, like a marriage license or divorce decree. Additionally, the form includes a declaration of the primary state of residence, which is necessary for compliance with the Nurse Licensure Compact. Nurses must also provide their contact information, including phone numbers and email addresses, to ensure proper communication regarding their request. While a replacement license is not issued upon approval of the name change, the updated information will be recorded with the ASBN. Clear instructions on payment methods, including credit card options, are also provided, along with a reminder that fees are non-refundable. Overall, this form is a straightforward process aimed at helping nurses maintain accurate records with the licensing board.
The Arkansas Name Change Request form is used by individuals to officially notify the Arkansas State Board of Nursing (ASBN) about a change in their name. This form ensures that the individual's nursing documentation reflects their current legal name.
There is no fee for submitting a Name Change Request. However, if a person is also requesting a license change, there is a fee of $30.00 for each license being updated.
Applicants must attach a copy of the legal document that supports their name change. Acceptable documents include:
The documents should show the newly changed name and must be submitted along with the request form.
No replacement license will be issued upon submission of the Name Change Request. However, the name change will be officially recorded with the ASBN.
The form requires the following information:
In the Name Change Request form, you must declare your primary state of residence by filling in the name of the state where you reside. This declaration is important for compliance with the Nurse Licensure Compact.
The ASBN accepts several payment methods for license change fees, including:
It is important to note that fees are nonrefundable.
If you have additional questions regarding the Name Change Request form, you can contact the Arkansas State Board of Nursing directly at 501-686-2700 or visit their official website at www.arsbn.org for more information.
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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When filling out the Arkansas Name Change Request form, it is important to follow specific guidelines to ensure a smooth process. Here are some things you should and shouldn't do:
Inaccurate Name Entry: One common mistake is entering the name incorrectly. It is essential to ensure that the name listed matches exactly with the legal documents. Any discrepancies can lead to delays or rejections.
Missing Required Documentation: Failing to attach the necessary legal documents, such as a marriage license or divorce decree, is another frequent error. These documents must be submitted to validate the name change request.
Incorrect Payment Method: Some individuals may overlook the payment details. While a name change request does not incur a fee, if a replacement license is requested, it requires payment. Ensure to select the correct payment method and include any applicable fees.
Omitting Contact Information: It is crucial to provide accurate contact details. Missing or incorrect phone numbers or email addresses can hinder communication regarding the status of the request.
Failure to Sign the Form: Lastly, neglecting to sign the form can result in an automatic rejection. The signature is necessary to validate the request and confirm that the information provided is accurate.