Request for Change of Address - California

BUREA
STATE OF CALIFORNIA BUSINESS, CONSU MER SERVICES, AND HOUSING AGENCY GOVERNOR EDMUND G. BROWN JR.
BUREAU OF SECURITY AND INVESTIGATIVE SERVICES
Po s t Office Box 989002
West Sacramento, CA 95798-9002
Phone (916) 322-4000 Fax (916) 575-7290
www.bsis.ca.gov
REQUE ST F OR CHANG E OF ADDRE SS
(Please type or print clearly)
Name:
License or Registration
Number(s)
Social Security or Individual Taxpayer Identification 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 i nclude a letter stating
that mail is undeliver a ble at your loca tion/physical ad dress or you are operating out of yo ur personal residence
requesting to use a mailing address instead of your location address. You must also provide the address of your
ph ysical location. (CCR §606).
OLD ADDRESS:
Address:
City: State: Zip Code
NEW ADDRESS:
Mailing Address:
City: State: Zip Code
Location/Physical Address
(D o not compl et e if you r ad dress is t h e same as your mailing addr es s.)
City: State: Zip Code
Please mail this form to the Bureau at the above address or fax to (916) 575-7290. Thank you.
California Code of Re gulations (CCR’ s) Section 60 6 (b) and the Ca liforni a Busine ss and P r ofessions 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. 07/2015
Page 1/1
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