Board of Geologist Registration

Address Change

Name as it appears on the license.
Last Name:
First Name:
Middle Initial:
License Number:
Effective Date:
Changes dated in the future won't be changed until the date noted, and a license reflecting the new address will be mailed close to the effective date of the change.

Old Email:
New Email:

New Business Address
Business Name:
Street:
City:
State:
Zip Code:
Telephone Number (inluding area code):
Email:

New Home Address
Street:
City:
State:
Zip Code:
Telephone Number (inluding area code):
Email:

Code
Please type the numbers displayed above in the box below.