Note to Students: By signing above, you authorize the release of name change documents, if requested, to the National
Student Clearinghouse for the purpose of notifying lenders and allowing employers and other authorized parties to verify your
enrollment and/or degree.
Please complete this form in its entirety and submit with the required documentation listed below.
Accepted Documents for Gender Change
Valid driver’s license or other government-issued photo ID reflecting the change
Accepted Documents for Name Change
Legible copy of a government-issued photo ID with new name
Court document reflecting name change
Marriage certificate
Copy of social security card with new name
Part 1: Gender Change
Are you requesting a gender change with the required documentation attached? _____YES _____NO
Requesting a gender change TO: _____MALE _____FEMALE
Part 2: Name Change
Former Name:
New Name:
Part 3: Contact Information
By submitting this form with required documentation and signing below, you are requesting that the Nazareth
College Registrar’s Office change your gender and/or your name. We will process your request within three
business days and will email you when it is complete.
_________________________________________________________ _____________________________
Signature Date
Office of the Registrar Smyth 1
4245 East Ave • Rochester, NY 14618
Phone (585) 389-2816 • Fax (585) 389-2612
First Name Middle Name Last Name
First Name Middle Name Last Name
ID#: Phone Number:
Email address: