Form DBPR AA-4102 "Request for Address/Name Change" - Florida

What Is Form DBPR AA-4102?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 29, 2012;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • 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 printable version of Form DBPR AA-4102 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR AA-4102 "Request for Address/Name Change" - Florida

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State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Request for Address/Name Change
Form # DBPR AA-4102
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
Applicants submitting a name change must submit:
Supporting legal documentation of name change (e.g. court documents showing name change,
marriage license, divorce decree, etc.)
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Registration
a. This form is required if you are an Athlete Agent and you are updating your personal
information with the Department of Business and Professional Regulation.
b. This form is also required if you are updating a business address with the Department of
Business and Professional Regulation.
2. Application Instructions (by section)
a. Section I- Transaction Types
i.
Select the transactions you wish to conduct. Note that you may complete multiple
transactions with this form at one time.
b. Section II - Applicant Personal Information
i.
Each applicant must provide their license number and the name on their current license.
ii.
For each transaction you wish to complete, fill out the appropriate section completely.
(1)
Change of Name: Applicant must provide their changed name with supporting legal
documentation showing the name change.
(2)
Change of Mailing Address: Applicant must provide their new mailing address.
(3)
Change of Residence Address: Applicant must provide their new residential address
if they have moved.
(4)
Change of Business Address: Applicant must provide their new business location
address if their business has changed locations.
c. Section III - Affirmation by Written Declaration
i.
Each applicant must sign the affirmation by written declaration.
DBPR AA 4102- Request for Address or Name Change
Incorporated by Rule: 61-35.004
May 29, 2012
1 of 3
State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Request for Address/Name Change
Form # DBPR AA-4102
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
Applicants submitting a name change must submit:
Supporting legal documentation of name change (e.g. court documents showing name change,
marriage license, divorce decree, etc.)
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Registration
a. This form is required if you are an Athlete Agent and you are updating your personal
information with the Department of Business and Professional Regulation.
b. This form is also required if you are updating a business address with the Department of
Business and Professional Regulation.
2. Application Instructions (by section)
a. Section I- Transaction Types
i.
Select the transactions you wish to conduct. Note that you may complete multiple
transactions with this form at one time.
b. Section II - Applicant Personal Information
i.
Each applicant must provide their license number and the name on their current license.
ii.
For each transaction you wish to complete, fill out the appropriate section completely.
(1)
Change of Name: Applicant must provide their changed name with supporting legal
documentation showing the name change.
(2)
Change of Mailing Address: Applicant must provide their new mailing address.
(3)
Change of Residence Address: Applicant must provide their new residential address
if they have moved.
(4)
Change of Business Address: Applicant must provide their new business location
address if their business has changed locations.
c. Section III - Affirmation by Written Declaration
i.
Each applicant must sign the affirmation by written declaration.
DBPR AA 4102- Request for Address or Name Change
Incorporated by Rule: 61-35.004
May 29, 2012
2 of 3
State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Request for Address/Name Change
Form # DBPR AA-4102
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the end of this application.
Section I – Transaction Type
TRANSACTION TYPE – Note: Choose all applicable transactions. [6001/9006]
Name Change
Change Residence Address
Change Mailing Address
Change Business Address
Change Contact Information
Section II – Applicant Personal Information
LICENSEE INFORMATION
Name:
License Number:
Phone Number:
Email Address:
NAME CHANGE
*Licensee Name (new, if applicable)
*NOTE: A change of name requires submitting supporting legal documentation of name change. See Instructions at
the beginning of this application for more information.
NEW MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
NEW RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
NEW BUSINESS LOCATION ADDRESS
Business/Firm Name
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
DBPR AA 4102- Request for Address or Name Change
Incorporated by Rule: 61-35.004
May 29, 2012
3 of 3
Section V – Affirmation by Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR AA 4102- Request for Address or Name Change
Incorporated by Rule: 61-35.004
May 29, 2012
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