Commonwealth of Virginia Department of Professional and Occupational Regulation 9960 Mayland Drive, Suite 400 Richmond, VA 23233 - 1485

NAME & ADDRESS CHANGE FORM

1. Select the profession/occupation for which you hold a license, certificate or registration:
Appraiser (R.E.) Architect Asbestos Auctioneer Backflow Prevention Device Worker Barber Body Piercer Branch Pilot Boxer Cemetery Company Cemetery Sales Personnel CIC Association CIC Manager Contractor Contractor - Tradesman Cosmetology Elevator Mechanic Engineer Esthetician Fair Housing Geologist Hair Braider Hearing Aid Specialist Home Inspector Interior Designer Land Surveyor Landscape Architect Lead Abatement Martial Arts Nail Technician Optician Onsite Sewage System Professional Polygraph Examiner Real Estate Soil Scientist Surveyor Photogrammetrist Tattooer Waste Management Facility Operator Wastewater Works Operator Waterwell System Provider Waterworks Operator Wax Technician Wetland Delineator Wrestling

2. License/Certificate/Registration Number(s):
0 2 2 5 1 9 8 0 9 6
Name on License T ELWOOD CUNNINGHAM Name on License Name on License

3. Name Change: Name change request must be accompanied by a copy of a marriage certificate, divorce Individual
Old Name:
Last Name First Name First Name Middle Middle
Generation

decree, court order, or other official documentation that verifies the name change.

New Name:
Last Name
Generation

Business Name You must read the Board's regulations to determine if you must complete a new application
for a new business entity.

New Business Name: Old Business Name:

Is this name change a result of a change of Ownership? No

Yes

(If yes, see Board Regulations for requirements)

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DPOR/NAME & ADDRESS CHANGE FORM Page of

4. Address Change: I am changing my address for:

A. Only this license/certificate/registration B. All my license(s)/certificate(s)/registration(s) with DPOR

(Please list all licenses/certificates/registration below or attach a separate sheet.)

I am changing my:
Physical Address: 602 PINE ROAD

1. Physical address (PO Box not accepted)

2. Mailing Address or

3. Both

Mailing Address: 602 PINE ROAD

City: FORT WASHINGTON State: MD Zip Code: 20744

City: FORT WASHINGTON State: MD Zip Code: 20744

5. Contact Information: Telephone No.: Facsimile No.: 6. Email Information: Old Email Address: New Email Address* : tristan.cunningham@gmail.com * Note: This will not change your existing User ID (log-in) when using DPOR on-line services.
Signature Date 10/18/2011 703-869-8405

Please sign and submit this form to the following address: Department of Professional and Occupational Regulation 9960 Mayland Drive, Suite 400 Richmond, VA 23233-1485

Print Form

NACHG 08/13/2010

DPOR/NAME & ADDRESS CHANGE FORM Page of