Name Change Form

This form may be submitted at any time, however, if your expiration date is within the next six (6) months it is suggested that you wait to include documentation with your Recertification Application. Please allow 2-10 business days for processing.  A new certificate(s) will be mailed to you.  To check on the status of your name change you must email PCB at Or you can check that status by searching your name in the Credential Search.

Files must be less than 2 MB.
Allowed file types: pdf doc docx.
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