Change of Address

Please provide the Board Examiners for Hearing Instrument Specialists with any change in your business and/or home address. Please use the form below to report address changes and/or remove address(es) from your record and click submit.

Only the licensee should change information on this site. By entering information on this site, you are representing that you are the person whose information is being changed.

Name as it appears on your license
Last Name: (Required)
First Name: (Required)
Middle Initial:
License Number: (Required)
Email:
Effective Date:
Changes dated in the future won't be changed until the date noted.
Please indicate whether you want information sent to your home or business address. * Required Home
Business

New Business Address
Business Name:
Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number:
(Please include area code)

New Home Address
Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number:
(Please include area code)

Old Business Address
Business Name:
Street (line 1):
Street (line 2):
City:
State:
Zip Code:
Telephone Number:
(Please include area code)

Old Home Address
Street (line 1):
Street (line 2):
City:
State:
Zip Code:

If you would like an updated copy of your license with your new address on it please check here:

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