Licensing Program 2005 Evergreen Street, Suite 1200 MEDICAL BOARD Sacramento, CA 95815-5401 Phone: (916) 263-2382 OF CALIFORNIA Fax: (916) 263-2487 Protecting consumers by advancing high quality, safe medical care. www.mbc.ca.gov Gavin Newsom, Governor, State of California | Business, Consumer Services and Housing Agency | Department of Consumer Affairs FICTITIOUS NAME PERMIT CHANGE OF ADDRESS FORM PLEASE PRINT OR TYPE ALL INFORMATION CLEARLY. FICTITIOUS NAME PERMIT #: FICTITIOUS NAME: PREVIOUS ADDRESS OF RECORD: CITY STATE ZIP COUNTRY PLEASE CHANGE MY ADDRESS OF RECORD TO: (Please allow only 30 characters per line for your address of record.) Note: Pursuant to Business and Professions Code Section 2021(a)(b), your address of record is public information and will be posted on the Medical Board222s Web site. CITY STATE ZIP COUNTRY YOUR ADDRESS OF RECORD CANNOT BE A POST OFFICE BOX, A STREET ADDRESS MUST BE REPORTED. PRACTICE TELEPHONE NUMBER: (PLEASE INCLUDE AREA CODE) I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT I AM A LICENSED PHYSICIAN OR PODIATRIST AND HAVE THE LEGAL AUTHORITY TO ACT ON BEHALF OF SAID FICTITIOUS NAME PERMIT HOLDER AND THAT THE INFORMATION CONTAINED ON THIS FORM IS TRUE AND CORRECT. PRINT OR TYPE NAME SIGNATURE DATE LICENSE # FNP-005 (Revised 01/2019) American LegalNet, Inc. www.FormsWorkFlow.com