state of maine
Department of Professional
and Financial Regulation
Bureau of consumer credit Protection
35 state house station
augusta, maine
04333-0035
		
Janet T. Mills		William N. Lund	
GOVERNOR		SUPERINTENDENT	

phone: (207)624-8527 (Voice)	
Printed on recycled paper
Offices located at:
 76 NORTHERN AVENUE, GARDINER, MAINE	

fax: (207)582-7699	

tty users call Maine relay 711
INTERNET: www.Credit.Maine.Gov

Name Change and/or Address Change Request Form

Please complete this form and return it to the Bureau of Consumer Credit Protection with the required supporting documentation and your payment of $25.

Please provide: 
•	A signed letter on company letterhead stating:
•	the previous company name and/or address;
•	the new company name and/or address; and
•	the date the change became or will become effective

•	Your original registration or license certificate. The Bureau will issue a new certificate once the name and/or address change has been approved and processed.

•	An original bond rider amendment reflecting the change, if applicable. Copies cannot be accepted.

•	For a name change: proof that you have the necessary form with the Maine Secretary of State to conduct business under the new name.

•	$25 administrative fee: 
•	Checks are to be made payable to “Treasurer, State of Maine”
•	Payment may also be made by credit card. To download the form:
•	Go to www.maine.credit.gov 
•	Click “Apply for a professional license”
•	Under your business category, click “Licensing/Registration Information”
•	Under forms and applications, click “Authorization of Credit Card Payment”

•	List the name and phone number of contact person(s) for:

•	Compliance Examinations	  _____________________________________________

•	Consumer Complaints	  _____________________________________________

		

Company representative preparing this request:

Signature:		____________________________________________________________________

Name (printed) and Title:	____________________________________________________________________

E-mail address:  		____________________________________________________________________

Telephone number:	____________________________ Fax number: _____________________________

Date:			____________________________