Healing Priory Name Change

In order to change the name of your healing priory/center, you must fill out this form. You are allowed one name change per center and after that any name changes will have a $199.00 fee.

1Form > 2Payment > 3Payment
First & Last Name
(This must be the director, owner or main principal of the healing center.) *
Current/Prior Name of Healing Center *
New Name of Healing Center *
Reason for the Name Change *
Your email:
(If you would like to received a copy of this submission, please enter your email below.)
By checking this box and signing below, I verify that I am an authorized personnel for this healing center and I have the authority to change the name of this healing center. I further verify that I agree to the changing of the name of this healing center and understand that by doing so, the next name change I will be required to pay a fee. *

By checking this box and signing below, I verify that I am an authorized personnel for this healing center and I have the authority to change the name of this healing center. I further verify that I agree to the changing of the name of this healing center and understand that by doing so, the next name change I will be required to pay a fee. I verify and agree.
Please draw/sign your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.