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State Board of Chiropractic Examiners

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Address Change Form

N.J.A.C. 13:45C-1.3(a)7 requires that all New Jersey licensees provide a timely notice of any change of address from that which appears on the licensee's most recent license renewal or application.

If your MAILING ADDRESS is not current, you will not receive your license renewal form or any other Board mailings. To ensure that you will receive all Board mailings you must immediately send the Board your current address information.

The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their consent. You are, however, required to provide an address that may be released to the public in our directories or in response to other requests. If you provide only your place of residence as your public address of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of your place of residence, use this form to provide an address of record other than your place of residence that may be released to the public.

An address of record may be a post office box address, only if another address with a street address is provided. If you do not indicate an address of record, we will assume that you have converted to the use of your mailing address as your address of record.

This change of address form may be completed and submitted electronically by clicking the "Submit the Form" button below to meet the address reporting requirement. This form is for address change reporting only.

Renewal Applications Are Not Forwarded
by the Postal Service to a Forwarding Address

* = required fields

Last Name*:
(as it appears on your license certificate)
First Name*:
(as it appears on your license certificate)
Two-Letter License Prefix*:     
(i.e. CCXXXXX, MZXXXXX, DIXXXXXX) The two letter prefix is found on your license certificate and precedes your 6-digit license number.)
License Number*:
(i.e. AI001200, AS089890, DI019980) The 6-digit license number is found on your license certificate after the two letter prefix.)

Date of Birth*:
(Use MM-DD-YY format. The date of birth will be used for verification purposes only.)

Daytime Telephone Number*:     
(Use 555-555-5555 format. The telephone will be used in the event that questions arise concerning this change of address form.)

E-mail Address:


Old mailing address

Street*:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

New mailing address
Is this your address of record? Yes No

Business or Practice Name*:
(if applicable)
Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

Note: If your mailing address is a business or practice location, you must provide the business or practice name in order to ensure mail delivery.

New business address
Is this your address of record? Yes No

Business or Practice Name*:
(if applicable)
Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)



New home address
Is this your address of record? Yes No

Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

 

           



Is this your address of record? Yes No
(You may only choose one address of record.)

New home address

Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

 

           

If you have made a legal name change it is imperative that this legal name change be reported immediately to the State Board of Chiropractic Examiners. You must mail the following items to the Board office c/o Professional Board Consumer Service Center, PO Box 45046, Newark, New Jersey 07101.

  1. Your PRINTED former name,
  2. Your PRINTED new name,
  3. Your license number (be sure to include the two-letter prefix with your license number) AND
  4. A copy of your marriage certificate, decree of divorce or court order.
   
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