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Get MI LARA/BPL-NAChg 2018

299 Name on Current License (including d/b/a, if applicable) Permanent ID Number New Name Requested (including d/b/a, if applicable) New Address Requested State City Phone Zip Code Email Address ___________________________________________________________________________ Signature _______________________________ Date FEE PAYMENT INFORMATION - CHECK ALL THAT APPLY ($10.00 PER LICENSE REPRINT) Name changes require license reprint; if request is for an address change only a reprint of the.

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