Change Licensing Information Form  


INTERNS (PT)         


Please provide us with any changed information so that we can make the corrections. Please allow 10 business days for any changes.  

This form is for Individuals Only!  Business must call the Reno Office at 1-800-364-2081.  


License Information (Required)

   Intern License # 

Personal Information

Current Name:  *First (Required)
Change Name to:  

New Personal Contact Information

Home Address:   City: State:    Zip:
 Home Phone:     
 Home Fax:      
  Email Address:  

Business Contact Information

  Store # / Name:
Store Address:   City:     State: Zip:  
Provide any other information you think we need: