Psp Change Of Name Or Address Application (Page 3 of 4) in pdf

PSP CHANGE OF NAME OR ADDRESS APPLICATION - INSTRUCTIONS

Completing the Application

This application form is to be used by a current certificate holder who desires to change

the name or address of his business where no change in the form of business, i.e., sole

proprietorship, corporation, etc., and no change in the responsible party is needed. If this

business is being sold or if the holder is incorporating, for example, this is not the

appropriate form. In cases such as those where there is a change in the form of business

or a change in responsibility, a new Application for PSP Certificate must be filed.

The blanks in the box at the top left corner of the application pertaining to Docket No.

(SC- ) and appearance of the notary's seal will be completed by the Chief Clerk when the

application is received at the Commission. The remainder of the application is to be

completed by the certificate holder and verified before a notary public.

The current name of the certificate holder must be the name which appears on the current

certificate.

The new name and new address will appear on the new certificate. The new name must be

the name of the responsible party and the new address must be the same as the address

which will be posted at the provider's PSP instruments. A certificate will be issued only in

the real name of the owner(s) or the corporate name.

If a trade name or dba name will be used to do business in North Carolina, the trade name

or dba name must be on file with the Commission and must be supported by the exhibit

specified in B. below. The certificate will be issued in the real name of the owner(s) or the

corporate name and a notation of the trade name or dba name (if any) will be made. This

application may be used to file a newly established trade name or dba name with the

Commission or to change a trade name or dba name by completing the "New Trade Name

or dba Name" blank. If no trade name or dba name will be used, simply type "N/A" in the

blank.

The PSP Change of Name or Address Application must be completed and signed by the

owner of a sole proprietorship, by a general partner of a partnership, by an officer of a

corporation, or by a responsible official for other certificate holders.

The application must be signed before a notary public and the name of the person who

completes and signs the application must be typed or printed by the notary in the space

provided in the verification section. The notary's name must be typed below the notary's

signature, or the notary's seal must be affixed to the original and each of the four (4)

copies.

Psp Change Of Name Or Address Application Page 3