Form CDPH8391 "Report of Name or Address Change" - California

What Is Form CDPH8391?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8391 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8391 "Report of Name or Address Change" - California

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State of California – Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
REPORT OF NAME OR ADDRESS CHANGE
California Code of Regulations, Title 17, Sections 30406 and 30537, requires any individual
issued an X-Ray Technician Limited Permit, Radiologic Technology Certificate, Mammographic
Certificate, Fluoroscopy Certificate, Supervisor and Operator Certificate or Permit, Fluoroscopy
Physician Assistant or a Nuclear Medicine Technologist Certificate to report any change in their
name or address within 30 days to this Department.
Pursuant to the California Code of Civil Procedure Section 1275, name change requests must be
accompanied by a copy of a certified superior court order allowing the name change and a
government issued picture ID, such as a driver’s license, military ID, or passport.
Are you taking a State examination? If yes, please check the exam category box below.
Supervisor/Operator
Radiologic Technologist
Limited Permit X-Ray Technician
Fluoroscopic Radiologic Technologist
Physician Assistant
Mammographic Radiologic Technologist
Current Certificate/Permit Number:
PREVIOUS NAME AND ADDRESS:
Name
Address
City, State, Zip Code
CURRENT NAME AND ADDRESS:
Name
Mailing Address (Number and Street or P.O. Box Number)
City, State, Zip Code
Daytime Telephone
E-mail Address
The information you provide on this form may be made public by the California Public Records Act;
please provide a P.O. Box number or other alternate address and/or an alternate phone number if
you do not wish to have your home address and/or phone number made public.
Signature
Date
A check or money order for $2 is required for duplicate requests of a permit/certificate, except
Nuclear Medicine Technologist certificates. For Nuclear Medicine Technologist certificates, a check
or money order for $18 is required for duplicate requests of the certificate. Please send payment
along with the form if you are requesting a duplicate copy of your permit/certificate once your name
and/or address is updated.
Radiologic Health Branch, MS 7610
P.O. Box 997414
Sacramento, CA 95899-7414
(916) 327-5106 ● (916) 440-7999 FAX
Internet Address:
Radiologic Health Branch Website Link
CDPH 8391 (Rev. 05/20)
State of California – Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
REPORT OF NAME OR ADDRESS CHANGE
California Code of Regulations, Title 17, Sections 30406 and 30537, requires any individual
issued an X-Ray Technician Limited Permit, Radiologic Technology Certificate, Mammographic
Certificate, Fluoroscopy Certificate, Supervisor and Operator Certificate or Permit, Fluoroscopy
Physician Assistant or a Nuclear Medicine Technologist Certificate to report any change in their
name or address within 30 days to this Department.
Pursuant to the California Code of Civil Procedure Section 1275, name change requests must be
accompanied by a copy of a certified superior court order allowing the name change and a
government issued picture ID, such as a driver’s license, military ID, or passport.
Are you taking a State examination? If yes, please check the exam category box below.
Supervisor/Operator
Radiologic Technologist
Limited Permit X-Ray Technician
Fluoroscopic Radiologic Technologist
Physician Assistant
Mammographic Radiologic Technologist
Current Certificate/Permit Number:
PREVIOUS NAME AND ADDRESS:
Name
Address
City, State, Zip Code
CURRENT NAME AND ADDRESS:
Name
Mailing Address (Number and Street or P.O. Box Number)
City, State, Zip Code
Daytime Telephone
E-mail Address
The information you provide on this form may be made public by the California Public Records Act;
please provide a P.O. Box number or other alternate address and/or an alternate phone number if
you do not wish to have your home address and/or phone number made public.
Signature
Date
A check or money order for $2 is required for duplicate requests of a permit/certificate, except
Nuclear Medicine Technologist certificates. For Nuclear Medicine Technologist certificates, a check
or money order for $18 is required for duplicate requests of the certificate. Please send payment
along with the form if you are requesting a duplicate copy of your permit/certificate once your name
and/or address is updated.
Radiologic Health Branch, MS 7610
P.O. Box 997414
Sacramento, CA 95899-7414
(916) 327-5106 ● (916) 440-7999 FAX
Internet Address:
Radiologic Health Branch Website Link
CDPH 8391 (Rev. 05/20)