I,_____________________________________________________ submit that my official mailing address is changed to:

________________________________________________________________________________________________

Street

_____________________________________________________            ____________________________________      City                                                                                                                                 State

______________________

Zip Code

The address change was/is effective on:_______________________________
                                                                                                  Date

_________________________________________________________________________

Signature

Mail to:    Bernice Berger
               Board of Chiropractic Examiners
               4201 Patterson Avenue
               Baltimore, MD 21215-2299