Iowa Department of Public Health - Protecting and Improving the Health of Iowans

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Request a Name or Address Change for a Business

License number:

Business name:

New business name (if applicable):

Address Information

Change address type:

Physical address Mailing address Billing address No change

Address line 1:

Address line 2:

City:

State:

ZIP code:

ZIP +4:

Contact Information

Contact name:

Daytime phone number:

(###) ###-####

Email address:

Confirm Email:

Message:

I affirm that the information that I have provided on this form is true and correct.