Board of Geologist Registration

Address Change

Name as it appears on the license.
Last Name:
First Name:
Middle Initial:
License Number:
Old Email:
New Email:
New Address
Street:
City:
State:
Zip Code:
Telephone Number:
Email:
Previous Address
Street:
City:
State:
Zip Code:
Telephone Number:
Email:
Code
Please type the numbers displayed above in the box below.