Change of Name

IMPORTANT:
In order to update your name, you must submit supporting documentation such as a copy of your marriage license or divorce decree.

PLEASE MAIL TO:
Missouri State Board of Optometry

P.O. Box 1335, Jefferson City, MO 65102-1335
Fax: (573) 751-8216
E-mail: optometry@pr.mo.gov

Licensee Information
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Previous Name:
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New Name(How it will appear on your license):
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Number of Duplicates: