Change of Address Form
DEPARTMENT OF HEALTH OFFICE OF PROFESSIONAL LICENSURE AND HEALTH PLANNING P.O. BOX 222995, CHRISTIANSTED, VI 00822-2995 CHANGE OF ADDRESS FORM USER FILLABLE FORM NAME: ____________________________________ _______________________________ _______ (PRINT) LAST FIRST MI LAST 4 DIGITS OF SSN: ____ ____ ____ ____ LICENSE #: _________________________ TELEPHONE #: ___________________________ EMAIL ADDRESS: ___________________________________________________________ OLD MAILING ADDRESS: NEW MAILING ADDRESS: SIGNATURE: ___________________________________ DATE: __________________ *EMAIL TO: PLHPDOCUMENTS@DOH.VI.GOV
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DEPARTMENT OF HEALTH OFFICE OF PROFESSIONAL LICENSURE AND HEALTH PLANNING P.O. BOX 222995, CHRISTIANSTED, VI 00822-2995 CHANGE OF ADDRESS FORM USER FILLABLE FORM NAME: ____________________________________ _______________________________ _______ (PRINT) LAST FIRST MI LAST 4 DIGITS OF SSN: ____ ____ ____ ____ LICENSE #: _________________________ TELEPHONE #: ___________________________ EMAIL ADDRESS: ___________________________________________________________ OLD MAILING ADDRESS: NEW MAILING ADDRESS: SIGNATURE: ___________________________________ DATE: __________________ *EMAIL TO: PLHPDOCUMENTS@DOH.VI.GOV