Who should submit this application?

QE Providers requesting to make changes to their provider license. Providers must submit this form at least 30 days in advance of any changes.

Helpful tips for filling out this application:

• Enter the current provider name and license number at the top of the form.
• Only complete the sections for which a change is being requested.
• Section 2 requires a recorded assumed name certificate if using an assumed name.
• Section 4 requires completion of the Principal Information Form.
• Section 5 requires proof of Power of Attorney for out-of-state applicants.
• Email competed form to Education@trec.texas.gov