3050 Martin Luther King, Jr. Drive Phone: (318) 670-9229
Shreveport, Louisiana 71107 FAX: (318) 670-6344
www.susla.edu registraroffice@susla.edu
The student must complete this form to change the legal name maintained on the student’s official SUSLA record
and submit it with supporting documentation to the Registrar’s Office. This form should be only to change your
name on the University’s official records, not to correct or adjust the spelling or format of your name.
If you have submitted an Application for Graduation, contact the Degree Auditor in the Registrar’s Office to
ensure that your updated name appears on the diploma and Commencement program.
Change of Name, Social Security Number or Date of Birth:
Please check the type of data requested for update:
Name Social Security Number (SS card required) Date of Birth (birth certificate required)
Current Name: SUSLA ID#
Last First Middle
Last 4-digits of SSN: DOB Phone: ( )
Address:
Street Address City ST Zip
Classification: SUSLA Skymail (Email): @susla.skymail.edu
Personal Email: ______________________________________________
Anticipated Graduation Date:
New Legal Name:
Last First Middle
Supporting Documentation: Driver’s License Social Security Card Military ID
(a minimum of 2 is required) Government ID Divorce Decree Passport
Birth Certificate Court Issued Document Marriage License
NOTE: Students who receive any form of federal or state student aid are required to change their name with the
Social Security Administration before changing their name with SUSLA.
Change of Address:
Please check the type of contact information that you want to change:
Home Address Mailing Address Address to send Diploma Work Phone Number
F-1 VISA Student Address Home Phone Number Mobile Phone Number
Current Address:
Street Address City ST Zip
New Address:
Street Address City ST Zip
Current Phone Number: New Phone Number:
Effective Date: Year Semester Fall Spring Summer
Student’s Signature: Date:
Records and Registration
Change of Name or Address Request
Freshman
Sophomore
RO: Change of Name/Address: Revised 07/14:07/16:08/19-LR
Registrar’s Office Use Only
Date Processed:
Processed by:
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome