Veterinarian Change Of Information Form
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Name: ____________________________________________________
License Number: ______________
What are you changing? Check all that apply.
HOME ADDRESS
PLACE OF EMPLOYMENT
LAST NAME
PREFERRED MAILING ADDRESS
PHONE NUMBER(S)
EMAIL ADDRESS
COMPLETE THE CHANGED INFORMATION BELOW
HOME ADDRESS INFORMATION:
New Home Address: __________________________________________________________ Apt. #: _________
City: ____________________________ State: ________ Zip: __________ County: _________________________
Phone: _________________ Email Address: __________________________________
EMPLOYMENT INFORMATION:
New Employer: _________________________________ _______________________________________________
Address: _______________________________________ _______________ City: ___________________________
State: _______ Zip: ______________ Work Phone: __________________________
LAST NAME INFORMATION:
Previous Last Name: ________________________________ New Last Name: ___________________________
**You are required to include a copy of the document that legally defines that change. **
PREFERRED MAILING ADDRESS:
Please select one:
HOME
PREMIS E
(AZ-licensed premise only)
NOTE:
By selecting “Home” or “Premise,” you are selecting the mailing address you wish the Board to mail you
all correspondence. Please be aware that the mailing address for some premises may not be the physical address,
so choose carefully. If your place of employment is outside of Arizona or is not an Arizona-licensed veterinary premise, all
correspondence will be mailed to your home address.
For public record requests, such as licensee directories, your home address will not be disclosed unless your place
of employment is outside of Arizona or is not an Arizona-licensed veterinary premise. If you fall into those categories, you
may provide written notification to the Board that you wish to use an alternative address, such as a P.O. Box for these
public information requests.
Please return your completed request form via fax, email, or mail to:
Arizona State Veterinary Medical Examining Board
9535 E. Doubletree Ranch Road, Suite 100, Scottsdale, AZ, 85258
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FAX:
(602) 364-1039
EMAIL:
kodi.calais@vetboard.az.gov
Questions? Phone (602) 542-8166
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