Change to Name, Mailing Address, or Point of Contact for Licensee/Registrant

Email address of person completing form:

Current Legal Name of Licensee or Registrant:

MCA License or Registration Number:

Federal EIN Number for Licensee or Registrants:

Is this form being submitted in relation to a recently approved request to transfer ownership of a licensed entity or a license?

YES

Select which of the following was approved by the Commission:

(1) the transfer of a controlling ownership interest in the entity holding the license

(2) the transfer of the license as an asset

Will the legal name (not the trade name) of the entity holding the license change as a result of the transfer?

Yes

Check the appropritate block(s) to indicate what you are seeking to change. MMCC WILL ONLY UPDATE THE INFORMATION CHECKED BELOW. A change to the legal and/or trade name will require MMCC approval. You will be advised via email when the legal and/or trade name is approved.

Change legal name of Licensee or Registrant (legal name change includes conversion to LLC, C Corp, etc.) *Requires printing of a new license ($50)

Change or add registered trade name for Licensee or Registrant. * Requires printing of a new license ($50)

Change current mailing address for Licensee or Registrant. *Requires printing of a new license ($50)

Change Authorized Point of Contact for Licensee or Registrant

The following documents (in .pdf format) must be submitted in support of a request to change the legal name of the Licensee or Registrant: 1. A copy of documentation showing that the requisite filing has been accepted by SDAT; and 2. A copy of documentation showing that the Licensee or Registrant is in good standing with SDAT.

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The following documents (in .pdf format) must be submitted in support of a request to change the trade name of the Licensee or Registrant: 1. A copy of documentation showing that the requisite filing has been accepted by SDAT; and 2. A copy of documentation showing that the Licensee or Registrant is in good standing with SDAT.

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Complete where applicable:

Enter new legal name (must match what is registered with SDAT):

Enter new trade name (must match what is registered with SDAT):

Enter new mailing address:

Enter the new Authorized Point of Contact for licensee (full name, title, email address and cell phone number):

Payment instructions:

For changes that require MCA to print and mail a new license (marked with * above), send a check or money order payable to MCA (ATTN: Mitch Parke) to MCA’s office at 849 International Drive, Linthicum, MD 21091. Include a printed copy of this form with the check.

ATTESTATION BY PERSON SUBMITING THIS FORM:

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First Name

Last Name

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I attest that I am authorized to complete this form on behalf of the Licensee/Registrant and that, to the best of my knowledge, the information reported on this form is accurate and complete.