New Jersey Division of Consumer Affairs

State Board of Medical Examiners

Change-of-Address Form for Physicians, Podiatrists and Lab Directors

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.

Be advised that your New Jersey licensing board/committee retains your: Home Address, Business Address and Mailing Address. One of these you determine to be your address of record. Your address of record is the address that will be printed on your renewed license certificate. Your name and this address, address of record, may also be posted as part of the Online Licensee Verification Directory. As a matter of information, under the public disclosure law as it currently stands, any of your license addresses (address of record, home, business and mailing) must be provided if requested under the Open Public Records Act. If you do not indicate an address of record, your mailing address will be considered your address of record. An address of record may be a post office box address, only if another address with a street address is provided.

This change of address form may be completed and submitted electronically by clicking the "Submit Change of Address Request" button below to meet the address reporting requirement. This form is for address change reporting only. If a duplicate license certificate with the new address is required, please mail a certified check or money order for $50.00 payable to the New Jersey State Board of Medical Examiners. Send to

New Jersey State Board of Medical Examiners
Licensee Service Center
PO Box 183
Trenton, NJ 08625-0183
Print your license number on the certified check or money order.

 

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 Alpha Code*: (Precedes five-digit license number)
Five-Digit License Number*: (Follows two-letter alpha code)
Date of Birth*:
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.)
Email Address*:



Old mailing address
business address
home address

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


New mailing address
Is this your address of record (the address that is seen by the public)? 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 (the address that is seen by the public)? 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 (the address that is seen by the public)? 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.)

Name Changes: Mail a copy of your marriage certificate, divorce decree or court order, your engrossed wall certificate (license) and your original certificate of registration (these documents will be reissued to you with your new name) to: New Jersey State Board of Medical Examiners, Licensee Service Center, PO Box 183, Trenton, NJ 08625-0150. Print your former name, complete license number (include the two letter prefix), and daytime telephone number on the copy of your name change documentation. If a duplicate license certificate is required, please mail a certified check or money order for $50.00, payable to the New Jersey State Board of Medical Examiners. Print your license number on the certified check or money order.