Name Change Request Form
A licensee shall notify the board of a name change within 30 days of the change. Please keep in mind this is public information.
Complete and submit this form to request a name change for your license. You must include a picture of the legal document that changed your name. Examples of accepted documents are: a marriage certificate, court order, or dissolution of marriage decree.
Please note: A Driver's License is not an acceptable document for a proof of name change.
Request a name change before renewing. For a new wall certificate, go to https://amanda-portal.idph.state.ia.us/ibpl/portal/#/dashboards/index to request from the online services option and pay the $20 fee.
Note: This form should not be used to change the name or owner of an establisment.
Important: A name change request can take between 24-72 hours to complete. Please do not request documents from the office until the name change is complete.