BUREA

STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GOVERNOR EDMUND G. BROWN JR. BUREAU OF SECURITY AND INVESTIGATIVE SERVICES

Post Office Box 989002

West Sacramento, CA 95798-9002

Phone 916-***-**** Fax 916-***-****

www.bsis.ca.gov

REQUEST FOR CHANGE OF ADDRESS

(Please type or print clearly)

Name:

License or Registration

Number(s)

Social Security Number Date of Birth

Phone Number (including area code):

If you are using a P.O. Box or mail box service address as your mailing address, you must include a letter stating that mail is undeliverable at your location/physical address or you are operating out of your personal residence requesting to use a mailing address instead of your location address. You must also provide the address of your physical location. (CCR §606).

OLD ADDRESS:

Address:

City: State: Zip Code

NEW ADDRESS:

Mailing Address:

City: State: Zip Code

Location/Physical Address

(Do not complete if your address is the same as your mailing address.) City: State: Zip Code

Please mail this form to the Bureau at the above address or fax to 916-***-****. Thank you. California Code of Regulations (CCR’s) Section 606 (b) and the California Business and Professions Code, Sections 7508.6, 7566, 7587.14, and 7599.59state that the Director may assess administrative fines against any licensee, registrant, or firearms qualification card holder for failure to notify the Bureau within 30 days of any change of residence or business address.

Signature Date:

Rev. 08/2013