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IF YOU NEED TO REPORT A NAME CHANGE, PLEASE COMPLETE THE NAME CHANGE FORM A406-ACHG-v6 Department of Professional and Occupation Regulation/ADDRESS CHANGE FORM 04/01/2020 Page of Commonwealth of Virginia Department of Professional and Occupational Regulation 9960 Mayland Drive, Suite 400 Richmond, Virginia 23233-1485 (804) 367-8500 www.dpor.virginia.gov ADDRESS CHANGE FORM Complete the information below for each license, certification or registration you hold from DPOR. Attach additional forms to include all license types with your submission. NOTE: Failure to list all licenses, certificates or registrations may result in not receiving important notices and/or information from the board that issued the license, certificate or registration. 1. Individual/Business Name Real Estate Individuals/Firms must use the board specific Name/Address Change Form. 2. Provide either your Social Security Number or VA DMV Control Number : - - State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles. (Individual license types only. Use number on file with the board.) 3. Date of Birth (If applicable) 4. Contact Numbers Primary Telephone Alternate Telephone 5. Current Mailing Address on record with the board: City State Zip Code 6. Requesting Address Change for: Virginia License Number: A. License Type: Name as it appears on License: NEW Mailing Address (PO Box accepted): City State Zip Code Check box if Street Address is the same as the Mailing Address. NEW Street Address (PO Box not accepted): City State Zip Code Virginia License Number: B. License Type: Name as it appears on License: NEW Mailing Address (PO Box accepted): City State Zip Code Check box if Street Address is the same as the Mailing Address. NEW Street Address (PO Box not accepted): City State Zip Code If changing more than two license types, please add an additional request form to your submission. Old E-mail Address New E-mail Address 7. NOTE: This will not change your existing User ID (log-in) when using DPOR on-line services. Email address is considered a public record and will be disclosed upon request from a third party. I certify that all information provided on this form is true and accurate, and that I am authorized to request the changes herein. 8. Date Signature Print Name Please sign and submit this form to the DPOR mailing address provided above or Fax to (866) 266-6818

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Page 1: Commonwealth of Virginia Department of Professional and ......NEW Mailing Address (PO Box accepted): City State Zip Code Check box if Street Address is the same as the Mailing Address

IF YOU NEED TO REPORT A NAME CHANGE, PLEASE COMPLETE THE NAME CHANGE FORMA406-ACHG-v6 Department of Professional and Occupation Regulation/ADDRESS CHANGE FORM04/01/2020 Page of

Commonwealth of Virginia Department of Professional and Occupational Regulation 9960 Mayland Drive, Suite 400 Richmond, Virginia 23233-1485(804) 367-8500www.dpor.virginia.gov ADDRESS CHANGE FORM

Complete the information below for each license, certification or registration you hold from DPOR. Attach additional forms to include all license types with your submission.

NOTE: Failure to list all licenses, certificates or registrations may result in not receiving important notices and/or information from the board that issued the license, certificate or registration.

1. Individual/Business NameReal Estate Individuals/Firms must use the board specific Name/Address Change Form.

2. Provide either your Social Security Number or VA DMV Control Number : - -

State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.

(Individual license types only. Use number on file with the board.)

3. Date of Birth (If applicable) 4. Contact Numbers Primary Telephone Alternate Telephone

5. Current Mailing Address on record with the board:

City State Zip Code

6. Requesting Address Change for:Virginia License Number:A. License Type:

Name as it appears on License: NEW Mailing Address (PO Box accepted):

City State Zip Code Check box if Street Address is the same as the Mailing Address.

NEW Street Address (PO Box not accepted):

City State Zip Code

Virginia License Number:B. License Type:

Name as it appears on License: NEW Mailing Address (PO Box accepted):

City State Zip Code Check box if Street Address is the same as the Mailing Address.

NEW Street Address (PO Box not accepted):

City State Zip Code

If changing more than two license types, please add an additional request form to your submission.Old E-mail Address New E-mail Address

7.

NOTE: This will not change your existing User ID (log-in) when using DPOR on-line services.Email address is considered a public record and will be disclosed upon request from a third party.

I certify that all information provided on this form is true and accurate, and that I am authorized to request the changes herein.8.

DateSignature Print NamePlease sign and submit this form to the DPOR mailing address provided above or Fax to (866) 266-6818

http://www.dpor.virginia.gov/uploadedFiles/MainSite/Content/FormsandApplications/A406-NAMECHG.pdf
www.dpor.virginia.gov
http://www.dpor.virginia.gov/Boards/Real-Estate/

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