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Address Name Change - TCLEOSE -

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Address Name Change - TCLEOSE - Powered By Docstoc
					    TEXAS COMMISSION ON LAW ENFORCEMENT OFFICER STANDARDS AND EDUCATION
                                             6330 E. Highway 290 , STE 200
                                             Au s t in , T e x as 7 87 2 3 - 10 3 5
                                                 Phone: (512) 936-7700
                                              http://www.tcleose.state.tx.us

                                       Address / Name Change
                                    Commission Rule § (211.27(c) (d))
                                                Please Print Legibly
                              Please mail to the address above or fax 512-936-7714.

CHECK IF:      ADDRESS CHANGE                       NAME CHANGE

1. Last Name (Name on File)                       2. First Name (Name on File)          3. M.I.   4. Suffix (Jr.,
                                                                                                  etc.)

5. TCLEOSE PID                                                    6. Date of Birth


New Name: (attach proof, certified copy of court order, marriage license, etc.)
7. Last Name                                        8. First Name                           9. M.I.    10. Suffix


 Previous Address:
11. Address                                                              12. City


13. State                     14. Zip Code                 15. Phone Number



 New Address:
16. Home or Permanent Mailing Address


17. City                                                   18. State                    19. Zip Code

20. Telephone                                                   21. E-mail Address


     I certify that the above information is true and correct, and may be used to update my
     TCLEOSE personal record.

  _________________________________________                                           ________________
  Signature of Licensee                                                                    Date




     Address/Name 4.30.2010

				
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