Form DBPR TA-4 "Application for Owner or Operator Name or Address Change" - Florida

What Is Form DBPR TA-4?

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 March 1, 2013;
  • 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 TA-4 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DBPR TA-4 "Application for Owner or Operator Name or Address Change" - Florida

Download PDF

Fill PDF online

Rate (4.8 / 5) 17 votes
State of Florida
Department of Business and Professional Regulation
Division of Professions: Talent Agencies
Application for Owner or Operator Name or Address Change
Form # DBPR TA-4
APPLICATION CHECKLIST – IMPORTANT – Submit items on the checklist below with your
application to ensure faster processing. Always keep a copy of your application and any
supporting documents submitted to the Department.
APPLICATION REQUIREMENTS
 Fees: No fee.
 Completed form DBPR TA-4 Application for Owner or Operator Name or Address Change.
 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
This application is only used for updating an owner’s name and residential address and / or the operators
name and residential address. Any changes to the talent agency license must be made through the
appropriate application.
1. Application Instructions (by section)
a. Section I- Individual’s Information
i.
For each transaction you wish to complete, fill out the appropriate section completely.
ii.
Change of Name: Applicant must provide their changed name with supporting legal
documentation showing the name change.
iii.
Change of Mailing Address: Applicant must provide their new mailing address.
iv.
Change of Contact Information: Applicant must provide their updated contact information.
v.
Change of Residence Address: Applicant must provide their new residential address if
they have moved.
b. Section II- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR TA-4 Name/Address Change
Eff. Date: 2013 March
Incorporated by Rule: 61-19.003
State of Florida
Department of Business and Professional Regulation
Division of Professions: Talent Agencies
Application for Owner or Operator Name or Address Change
Form # DBPR TA-4
APPLICATION CHECKLIST – IMPORTANT – Submit items on the checklist below with your
application to ensure faster processing. Always keep a copy of your application and any
supporting documents submitted to the Department.
APPLICATION REQUIREMENTS
 Fees: No fee.
 Completed form DBPR TA-4 Application for Owner or Operator Name or Address Change.
 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
This application is only used for updating an owner’s name and residential address and / or the operators
name and residential address. Any changes to the talent agency license must be made through the
appropriate application.
1. Application Instructions (by section)
a. Section I- Individual’s Information
i.
For each transaction you wish to complete, fill out the appropriate section completely.
ii.
Change of Name: Applicant must provide their changed name with supporting legal
documentation showing the name change.
iii.
Change of Mailing Address: Applicant must provide their new mailing address.
iv.
Change of Contact Information: Applicant must provide their updated contact information.
v.
Change of Residence Address: Applicant must provide their new residential address if
they have moved.
b. Section II- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR TA-4 Name/Address Change
Eff. Date: 2013 March
Incorporated by Rule: 61-19.003
State of Florida
Department of Business and Professional Regulation
Division of Professions: Talent Agencies
Application for Owner or Operator Name or Address Change
Form # DBPR TA-4
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 beginning of this application.
Section I- Individual’s Information
INDIVIDUAL’S INFORMATION
Name (previous):
Owner
Operator
*Name (new, if applicable):
*NOTE: A change of name requires submitting supporting legal documentation of name change.
NEW MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
NEW RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
Section II – 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 TA-4 Name/Address Change
Eff. Date: 2013 March
Incorporated by Rule: 61-19.003
Page of 2