In accordance with the information contained in this application, I hereby apply for a change of Trade Name and/or address and request the issuance of a new certificate of licensure for the current year. Please print or type all information.

1. Name of Applicant ___________________________________________________
License No. ______________
2. New Firm Name, if applicable
____________________________________________________________________

3. State reasons for requesting a change of trading name ____________________________________________________________________
____________________________________________________________________
4. New Mailing Address, if applicable ____________________________________________________________________
____________________________________________________________________
Telephone Number ___________________________
5. Name of owner or officers of contracting firm ____________________________________________________________________
____________________________________________________________________

6. I will be regularly employed with the firm listed above (number 2). in the capacity of _____________________________. My signature and license number will appear on all contracts of this firm and I will exercise general supervision of all work done thereunder as prescribed in Article 5, Chapter 87 of the General Statutes of North Carolina.
7. I am returning with this application, my old certificate of licensure.
8. I hereby certify that the forgoing statements are true and correct to the best of my knowledge and belief.
Signature of Applicant ___________________________________
Social Security Number ___________________________________

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