Change of Name and/or Address Please provide the Missouri State Board of Nursing with any change in your name and/or address. Please use the form below to report name and 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:

Changes dated in the future won't be changed until the date noted.

Change of Last Name:

New Primary Address: (Physical address required, PO Boxes are not acceptable)

New Mailing Address: (Only required if your mailing address is different that your primary address)

Remove the Following Address from my Record:

 

I declare as my primary state of residence effective .

I am employed exclusively in the U.S. Military (Active Duty) or with the U.S. Federal Government and am requesting a Missouri single-state license regardless of my primary residence.

Information on the Nurse Licensure Compact can be found at www.ncsbn.org/nlc.htm.
In accordance with the Nurse Licensure Compact "Primary State of Residence" is defined as the state of person's declared fixed, permanent and principal home for legal purposes; domicile. Documentation of primary state of residence may be requested (but not limited to) included:

  • Driver's license with a home address
  • Voter registration card displaying a home address
  • Federal income tax return declaring primary state of residence
  • Military Form no. 2058 - state of legal residence certificate
  • W-2 from US Government or any bureau, division or agency thereof indicating the declared state of residence

Proof of any of the above may be requested.


When your primary state of residence is a non-compact state, your license will be designated as a single-state license valid only in Missouri.

When your primary state of residence is a compact state other than Missouri, your license will be placed on inactive status and you can practice in Missouri based on your unrestricted multi-state license from another compact state.

Code

Please type the numbers displayed above in the box below.

By signing in the box below, I declare that statements and representations submitted with this change request are made under oath or affirmation and are true and correct to my best knowledge under penalty of section 375.060, RSMo, which specifies that anyone who makes a false statement in writing with intent to mislead a public official in the performance of his official duties is guilty of a class B misdemeanor.