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Change of address form

Change of Address Form
(PLEASE PRINT IN ALL SPACES TO ENSURE LEGIBILITY)

Licensees are required to use NIPR’s online update to change addresses. Only use this form when:

You are moving from/into a new state (NOT North Carolina) *
You are an adjuster domiciled in a state other than your resident state *
You are updating the address of a Business Entity
______________________________________________
____________________________________

* List Domicile State _________________________
A domicile state is the state in which you qualified for a license by exam and continue to maintain an active license. The
state listed above may be your resident state or an adopted home state.

_____________________________________________________________________________________________________________________________________


_____________________________________________________________________________________________________________________________________

City
E-Mail Address (N.C. GENERAL STATUTE REQUIREMENT FOR ALL LICENSEES)

_________________________________________________________________________________________



New Business Address

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_________________________________________________________________________________________

New Mailing Address □ Residence Address Listed Above
_________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

City

_____________________________________________
___________________________________
Mail to: NC Licensing Office of Pearson Vue, PO Box 14209, Raleigh, NC, 27620 or fax to (888) 959-3010 or email to: Northcarolinalicensingoffice@pearson.com According to N.C.G.S. 58-2-69(b): Every licensee shal give written notification to the Commissioner of any change of the licensee's residential address within 10 business days after the licensee moves into their new residence. Effective 01/01/2010, Every licensee shal provide a valid e-mail address and give written notification to the Commissioner of any change to the licensee’s email address within 10 business days after the change. Failure to update resident address or e-mail within 10 business days shal result in a $50.00 fee.

Source: http://www.ncdoi.com/asd/Documents/ApplicationsAndForms/Licensee%20Change%20of%20Address%20Form_AA_BE_BB.pdf

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