Change Licensing Information Form
|
CONTROLLED SUBSTANCE (CS)
|
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)
|
| |
CS License #
|
|
|
Personal Information
|
| Current Name: |
*First
|
Middle
|
Last
|
| Change Name to: |
|
|
|
| |
Practice Name & Contact Information
|
REMEMBER: Anyone holding a controlled substance license (Practitioner) may not change to a home address. A Nevada practicing address is REQUIRED. If you no longer practice in Nevada, you must notify our office by clicking HERE and e-mailing us that you have left the state of Nevada.
|
| New Practice Name: |
|
| New Practice Address: |
|
City: |
NV Zip: |
| Phone #: |
|
|
|
| Fax #: |
|
|
|
| Email Address: |
|
| |
Provide any other information you think we need: |
| |
|
| |