License Change Application Form

LICENSE CHANGE APPLICATION FORM

Whereas

WHEREAS, Applicant seeks to amend certain information recorded on License Number issued by the Licensing Authority;

WHEREAS, the Licensing Authority requires a formal application and supporting declarations to review and approve changes to a license, including verification of identity, business status, and payment of any applicable fees; and

WHEREAS, the parties intend that any approval of the requested change will be documented by the Licensing Authority and that this form, when signed, will govern the processing of the requested modification.

Applicant Information

Requested Change(s)

Indicate the specific change(s) requested (check all that apply):

Ownership change Address change Trade name change

Business activity change Other (describe below)

Proposed effective date of change:

Scope of Work / Processing

Describe the actions to be performed by the Licensing Authority in processing this application (administrative review, inspections, issuance of amended license, record updates). Specify attachments and supporting documents submitted with this form.

Payment Terms

Applicant agrees to pay the required processing fee and any additional charges incurred during review. Fees must be received prior to issuance of any amended license unless otherwise authorized in writing by the Licensing Authority.

Late fee on overdue balances shall be or the maximum permitted by applicable law, whichever is less.

Term and Termination

This application governs the processing of the requested change from the date of receipt by the Licensing Authority until final disposition of the application or the effective date of the approved change, whichever is later.

Start date:

End date (if applicable):

Confidentiality

The Licensing Authority and Applicant each acknowledge that certain information submitted with this application may be confidential. To the extent permitted by law, both parties shall maintain confidential information in confidence and shall not disclose such information except as required by statute, regulation, court order, or as necessary to process the application. Confidential information excludes information that is or becomes publicly available through no breach of this provision or was independently developed or lawfully obtained by the receiving party.

Applicant acknowledges that disclosure to third parties may be required for inspection, verification, or enforcement purposes and consents to such limited disclosures.

Applicant affirms: I have read and understand the confidentiality provisions above.

Governing Law

This application and any decision arising from it shall be governed by the laws of the state or jurisdiction in which the license is issued. All disputes arising out of or relating to this application shall be resolved in the competent courts of that jurisdiction.

Entire Agreement

This form, together with any attachments, declarations, and fee receipts, constitutes the entire agreement between Applicant and the Licensing Authority with respect to the subject matter hereof and supersedes all prior written or oral communications relating to the requested license change.

Applicant Certification

The Applicant certifies under penalty of perjury that the information provided on this application and the accompanying documents is true, complete, and accurate to the best of the Applicant’s knowledge. Applicant understands that knowingly making a false statement may result in fines, revocation of a license, or other enforcement actions permitted by law.

Applicant: I certify the above.

Supporting Documents

List documents submitted with this application (e.g., identification, deed, articles of amendment, fee receipt, inspection report).

Administrative Use Only

Fee Received: Receipt/Reference #:

Processing Officer:

Decision: Decision Date:

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