"Name Change Request Form" - Arkansas

Name Change Request Form is a legal document that was released by the Arkansas Contractors Licensing Board - a government authority operating within Arkansas.

Form Details:

  • Released on January 1, 2019;
  • The latest edition currently provided by the Arkansas Contractors Licensing Board;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Contractors Licensing Board.

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Download "Name Change Request Form" - Arkansas

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ID#__________
CONTRACTORS LICENSING BOARD
4100 Richards Road
North Little Rock, AR 72117
501-372-4661 / Fax 501-372-2247
Name Change Request Form
Current:
Company Name:
(as it appears on the license now)
___________________________________________________________
_______________
_______________
Federal ID#/EIN:
or SS#
(if sole-proprietor)
Request to Change to:
Company Name:
___________________________________________________________
_______________
_______________
Federal ID#/EIN:
or SS#
(if sole-proprietor)
AFFIDAVIT
I, ______________________________________________,
:
being duly sworn, deposes and says
(Print Name of Owner/Officer/Partner/Member)
That all statements herein contained are true and correct and shall become a part of the present valid
application on file. That the foregoing statement is submitted to the Contractors Licensing Board and/or
Contractors Residential Committee for the purpose of amending the present valid license and that any
depository, vendor or other agency herein named is hereby authorized to supply the Contractors Licensing
Board and/or Contractors Residential Committee with any information necessary to verify these statements.
__________
(Signature of Owner/Officer/Partner/Member)
_____________________
STATE OF
___________________
COUNTY OF
Subscribed and Sworn to before me, a Notary Public, this ______ day of _________________, 20_____.
Notary Public / Seal
Revised 01/2019
ID#__________
CONTRACTORS LICENSING BOARD
4100 Richards Road
North Little Rock, AR 72117
501-372-4661 / Fax 501-372-2247
Name Change Request Form
Current:
Company Name:
(as it appears on the license now)
___________________________________________________________
_______________
_______________
Federal ID#/EIN:
or SS#
(if sole-proprietor)
Request to Change to:
Company Name:
___________________________________________________________
_______________
_______________
Federal ID#/EIN:
or SS#
(if sole-proprietor)
AFFIDAVIT
I, ______________________________________________,
:
being duly sworn, deposes and says
(Print Name of Owner/Officer/Partner/Member)
That all statements herein contained are true and correct and shall become a part of the present valid
application on file. That the foregoing statement is submitted to the Contractors Licensing Board and/or
Contractors Residential Committee for the purpose of amending the present valid license and that any
depository, vendor or other agency herein named is hereby authorized to supply the Contractors Licensing
Board and/or Contractors Residential Committee with any information necessary to verify these statements.
__________
(Signature of Owner/Officer/Partner/Member)
_____________________
STATE OF
___________________
COUNTY OF
Subscribed and Sworn to before me, a Notary Public, this ______ day of _________________, 20_____.
Notary Public / Seal
Revised 01/2019
Name Change
A name change is simply amending the existing entity’s name with
no change in the actual business structure, which means you CAN
NOT DISSOLVE the existing entity and transfer the license to an
already existing or newly formed entity.
A name change can only be done if a “conversion” or “amendment”
is filed with the Secretary of State, and there is NO change in the
Federal ID#/EIN.
** Anything else requires a New Application. **
If requesting a Name Change, please provide the following:
. Name Change Request Form (Completed, signed and notarized)
1
. Provide copies of all supporting documents from the Secretary of State’s office.
2
. Updated Certificate of Insurance verifying Workers Compensation insurance for the new
3
entity.
A list of current officers, members or partners owning 10% or more.
4.
An “endorsement rider” is required to amend name on bond to reflect new name.
5.
(If a Commercial Contractor Only)
Should you have further questions regarding this form, please contact Darlene Akel at
Darlene.akel@arkansas.gov
or 501-371-1508. Please provide the ID# in the top “right”
corner of your current license, upon emailing or calling so we can best serve you.
Revised 01/2019
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