THE STATE                                                                                                       BUS 
                of                                                                          FOR DIVISION USE ONLY 
                    ALASKA                                                                               
               Department of Commerce, Community, and Economic Development 
               Division of Corporations, Business and Professional Licensing 
 
     Department of Commerce, Community, and Economic Development 
     Division  of Corporations, Business and Professional Licensing 
     Business Licensing Section 
     333 Willoughby Avenue, 9 thFloor, Juneau, AK  99801 
                 
     PO Box 110806, Juneau, AK  99811-0806 
     Phone: (907)   465-2550     • Fax: (907) 465-2974 
     Email: BusinessLicense@Alaska.Gov 
     Website: BusinessLicense.Alaska.Gov 
 
 Business License: Owner’s Legal Name Change 
 
                                                                                          12 AAC 02.900(c) 
  This form is ONLY to notify the Business Licensing Section when there is a LEGAL name change of the owner of the 
  business license. Per 12 AAC 02.900(c), notification of an owner’s name change must be submitted to this office 
  within 30 days of the change. 
   
  NOTE: A legal name change means there has been a LEGAL change of the name of the business owner due to a 
  LEGAL event such as, but not limited to: marriage, divorce, court-approved legal name change, or if the owner is an 
  entity and the entity has amended (legally changed) its name on record with the Corporations Section. 
   
  This form is NOT for a change in ownership (who owns the business license). A business license is NOT transferable 
  or assignable. A change in the ownership in the business requires a new business license. 
   
  For more information regarding business licensing, go to: www.BusinessLicense.Alaska.Gov 
   
  IMPORTANT: Separate notification may be required to notify the Corporations Section and Professional Licensing 
  Section. For more information, go to: 
    www.Corporations.Alaska.Gov 
    www.ProfessionalLicense.Alaska.Gov 
   
  Online filing is not available for this form. Submit this form by fax or mail. Do not email this form or payment. 
   
  Processing Time: Standard processing time from March-September is 10-15 business days. During heavy 
  business license filing seasons, October-February, the processing time will be delayed. 
 
                                                                             12 AAC 02.105(3) and AS 08.01.010(10) 
                                                                                                                                 
  Required Fee:             Non Refundable Filing Fee          (BUS1)                                               $5.00 
                                                                                                                                 
  Mail or fax this form and the non-refundable $5 filing fee in U.S. dollars to the letterhead address. Make the check or 
  money order payable to the State of Alaska, or use the attached credit card payment form. 

   1.  Business License Name:  (must match name on the business license certificate. 

   Business License Name:                
                                                                                                                                
   Business License Number  (mandatory):                                                                                        
                                                                                                                                
  08-4104        Rev. 10/01/17          BL Owner’s Legal Name Change Page 1 of 2 

2. Current Name of Owner: The owner’s name as it currently appears on the business license prior to this filing.

   CURRENT Owner’s Name: 

3. New Name of Owner: The owner’s name as it will appear on the business license as a result of this filing.

   CURRENT Owner’s Name: 

   If the owner is an entity (corporation, LLC, etc.), then provide its Alaska Entity Number: 
             Not Applicable 
             Alaska Entity Number: 

4. Evidence of Legal Name Change:

           I have attached a copy of the legal name change document supporting the owner’s legal name change. 

5. Signature:

   The request to change the owner’s legal name for this business license must be signed by the owner of the
   business.
          If the business is a sole proprietor, then the sole individual owner must sign.
          If the business is a partnership, then one of the owning partners must sign.
          If the business is owned by an entity, then the signer must be on the record with this office as an
           authorized signer for the owning entity and identify their signing authority, such as: corporation
           President or LLC member. Example: John Doe, President of owning entity XYZ Incorporated.

   By my signature below, I declare under the penalty of perjury that the information provided on the application 
   is true and correct to the best of my knowledge: 

   Signature of Owner:                                               Date: 

Printed Name of Owner: 

           Title of Owner: 
                             (Provide title based on the type of organization, such as; Sole Proprietor, Partner, or 
                             President of <owner entity name>, etc.) 

                            Additional Fee: $5 per copy 
                            If you want this office to mail a copy of the updated business license, 
Select one of the           Submit to this office, Business License: Certificate Copy Request 
following options           (form 08-4080), along with the appropriate fees. 
for after the filing 
has been 
processed:                  Free: 
                            Print a copy of the updated business license from the web at: 
                            www.BusinessLicense.Alaska.Gov 

Address Change: If the businesses physical and/or mailing addresses have changed, submit Business License 
Change of Address Form (08-4054) along with the appropriate fee. 

08-4104      Rev. 10/01/17    BL Owner’s Legal Name Change Page 2 of 2 

               THE STATE                                                                                        FOR DIVISION USE ONLY 
                of 
                  ALASKA 
                Department of Commerce, Community, and Economic Development 
                Division of Corporations, Business and Professional Licensing 

   State of Alaska 
   Department of Commerce, Community, and Economic Development 
   Division of Corporations, Business and Professional Licensing 
   333 Willoughby Avenue, 9th Floor, Juneau, AK 99801 
   PO Box 110806, Juneau, AK 99811 
   Phone: (907) 465-2550    • Fax: (907) 465-2974 

CREDIT CARD PAYMENT 

For  security  purposes  please       do  not  email  credit  card  information.  Fax  or  mail  this  credit  card 
payment  form  to  the  Division.  Completion  of  this  form  is  not  proof  of  payment  until  the  Division 
processes the information. If any information on this form is illegible, the form will be rejected. 

Name of Applicant or Licensee:  ________________________________________________________________________________________________________________________ 

Type of License:  _____________________________________________________ License Number (if applicable):    ____________________________________ 

 I wish to make payment by credit card for the following                                (check all that apply):          Amount

         Application Fee:  __________________________________________________________________                       _______________________

         License or Renewal Fee:  __________________________________________________________________                _______________________

         Other (name change, wall certificate, fine, duplicate license, exam, etc.):  
            1. __________________________________________________________________                                   _______________________ 

            2. __________________________________________________________________                                   _______________________

                                                                                                               Total:  _______________________ 

Name (as shown on credit card):  ________________________________________________________________________________________________________________________ 

Mailing Address:  ____________________________________________________________________________________________________________________________________________________ 

Phone:  ______________________________________________          Email (optional):       ___________________________________________________________________________________ 

Credit Card Type:                     VISA              — or —                          Mastercard 

            Signature of Credit Card Holder:                          ___________________________________________________________________________________________________

VISA or Mastercard Number: __________________________________________________________       Expiration Date:        ______________________________ 

            This section below the dotted line will be destroyed upon processing of the payment. 

 08-4438           Rev. 12/22/16                                         Credit Card Payment Form