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After completing last field, save document to hard drive to make future updates or click Print button.   \n100 North First Street, E-240 Springfield, Illinois 62777-0001  \n!73-71  \nLICENSURE UPDATE REQUEST  \nEDUCATOR EFFECTIVENESS DEPARTMENT  \nDirections: Please print or type the information requested, and sign in ink. Return this completed form to the address above. You can also email your form and required documents to [licensureforms@isbe.net](licensureforms@isbe.net).  \n\n| NAME (Last, First, MI, Maiden) | IEIN | DATE OF BIRTH (MM/DD/YYYY) |\n| --- | --- | --- |\n| CURRENT ADDRESS (Street, City, State, ZIP Code) | TELEPHONE (Include Area Code) |  |\n|  | EMAIL |  |\n\nPART I NAME CHANGE – Attach a copy of an official document verifying the name change.  \n\n| CHANGED FROM | CHANGED TO |\n| --- | --- |\n\nPART II DATE OF BIRTH CORRECTION – Attach a copy of an official document verifying the correct date of birth.  \n\n| CHANGED FROM | CHANGED TO |\n| --- | --- |\n\nDirections: This form and a copy of a Social Security card may be uploaded by a Regional Office of Education (ROE) . See the ISBELicensure Message Center webpage. The information also may be uploaded by an institution of higher education (IHE) if the educator is actively enrolled in a preparation program or it can be emailed to [licensureforms@isbe.net](licensureforms@isbe.net. City of Chicago teachers may mail)[. City of Chicago teachers may mail](licensureforms@isbe.net. City of Chicago teachers may mail) their form and card directly to the Educator Effectiveness Department at ISBE using the address at the top of this form. ROE/IHE upload is preferable because email transmission of sensitive documents is not secure.  \nPART III SOCIAL SECURITY NUMBER CORRECTION–Attach a copy of an official document verifying that the Social Security number is correct.  \n\n| CHANGED FROM | CHANGED TO |\n| --- | --- |\n\nI do hereby affirm that the above information is true, accurate and complete.  \nDate Digital or Original Signature","cbCaitsDWek6KJkl","https://ap.wps.com/l/cbCaitsDWek6KJkl","pdf",417682,"English","# LICENSURE UPDATE REQUEST\n## Directions and Submission\n## Part I Name Change\n## Part II Date of Birth Correction\n## Part III Social Security Number Correction","[{\"question\":\"What information is required to complete the licensure update request form?\",\"answer\":\"The form requests the educator’s name, IEIN, date of birth, current address, telephone, and email.\"},{\"question\":\"What documents must be attached for a name change?\",\"answer\":\"Attach a copy of an official document verifying the name change, then fill in the changed-from and changed-to fields.\"},{\"question\":\"What are the available submission methods for this form?\",\"answer\":\"You can print and mail the completed form, email it with required documents, or upload it through a Regional Office of Education or an institution of higher education; uploads are preferred for sensitive documents.\"}]","LICENSURE UPDATE REQUEST - Part 1-3 Name Change and Corrections | PDF",1791597075]