Request For Reissuance Of Appraiser Wall Certificate And Pocket Card Due To Name Change - North Carolina Appraisal Board
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1Board Use Only
NORTH CAROLINA APPRAISAL BOARD
Amt Received: _____________
5830 Six Forks Road, Raleigh, NC 27609
Trans. No.: ________________
Phone: 919/870-4854
Website:
REQUEST FOR REISSUANCE OF APPRAISER
WALL CERTIFICATE AND POCKET CARD
DUE TO NAME CHANGE
Fee Schedule: $10.00 for a new wall certificate; $10.00 for a new pocket card
(Total = $20.00, payable to the NC Appraisal Board)
Instructions: when your name changes, the NC Appraisal Board must process a new pocket card and a new wall
certificate. Along with this form and your registration, license or certificate, you must submit a copy of your marriage
certificate or legal document showing name change. If your mailing address has changed, please be advised that you
need to fax or mail a completed Change of Address form to us. [Note: submitting a new address on the Request for
Name Change form will NOT officially change your address in our database.]
I hereby certify to the North Carolina Appraisal Board that my name was legally changed as follows and I therefore
request that my appraiser registration, license, or certificate be reissued accordingly:
Your previous name: _____________________________________________________________________________
(First Name)
(Middle Name)
(Last Name)
Your new/current name: ___________________________________________________________________________
(First Name)
(Middle Name)
(Last Name)
Your name was legally changed on _____________________ by reason of __________________________________.
(Date)
***************************************
By signing below you understand that you will be issued a new pocket card and a new wall certificate, and your name
will officially be changed in our records. Also, if you are licensed or certified, you will be mailed a new seal
authorization along with your new pocket card and wall certificate.
***************************************
Print your name exactly as you would like your name to appear on your new pocket card and wall certificate, and, if
applicable, seal authorization:
____________________________________________________________________
Signature: ______________________________________________________________________________________
Date: _______________________________________________
Appraiser Number: ___________________
Appraiser Type:
Reg. Trainee
Res. License
Res. Certification
Gen. Certification
Mailing address where this parcel is to be delivered: ____________________________________________________
_______________________________________________________________________________________________
Rev 4/23/08
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