Change of Address/ Name form
Please complete all fields below and mail, fax or deliver to the Registrar’s Office.
Current Name: ____________________________________________________________________________
Last First M.I. Maiden/Former
Student ID or Social Security Number: ________________________________
Legal Name Change: Please attach supporting documentation (marriage license, driver’s license, etc.). Before
submitting this form to OHSU, it is important that the change is also made with the Social Security
Administration or visit www.ssa.gov.
This section is for current students only. If you are a former student, your student records will reflect the
name that this office had on file at the time of graduation or the time that you discontinued your enrollment.
Reason for name change: New legal name New married name Former name
New Name: _______________________________________________________________________________
Last First M.I. Maiden/Former
Mailing Address Changed To: (Please Print)
________________________________________________________
Mailing Address
________________________________________________________
City State Zip
________________________________________________________
Phone Number
________________________________________________________
Student Signature Date
Change of Address/Name Form
Phone: 503-494-7800
Fax: 503-494-4629
Mail code L-109, Mackenzie Hall 1120
3181 SW Sam Jackson Park Rd.
Portland, OR 97239
503-494-7800 phone
