Board of Optometry

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Board of Optometry

Change of Name

Name Change

Profession:
License Number:
Previous Name:
First:
Middle:
Last:
Suffix:
New Name: (How it will appear on your license)
First:
Middle:
Last:
Suffix:
Phone Number:
Number of Duplicate Copies of License

IMPORTANT:
In order to update your name, you must submit supporting documentation such as a copy of your marriage license or divorce decree.

PLEASE MAIL TO:
Missouri State Board of Optometry
P.O. Box 1335, Jefferson City, MO 65102-1335
Fax: (573) 751-8216
E-mail: optometry@pr.mo.gov