Official Name Change
Form
INSTRUCTIONS: This form is to be submitted by the student to declare a change of name for academic record purposes.
Original or certified copy of official legal documentation must be submitted along with this form. Please allow five
business days for processing of a name change.
REQUIRED DOCUMENTATION – Please select from the following and submit original or certified copy of legal
documentation that shows your new name. Please check one of the following. A copy will be made of your original
document and the original will be returned to you.
Valid driver’s license bearing a photogram of the person
Marriage certificate and photo ID
Certified record of divorce and photo ID
Per FAFSA result (ISIR), name passed database matches with SSN and DOB
Certified court order and photo ID
Valid unexpired U.S. Passport issued in your new name
Wisconsin ID card issued under 343.50, bearing a photograph of the person
Armed forces of the U.S. ID card issued to military personnel (Access Card of DD Form 2)
STUDENT INFORMATION:
Student ID __________________________________________________________ Date of Birth __________________
CURRENT Name on Record:
Last __________________________ First _________________________ Middle ______________ Suffix (e.g., Jr., II)
NEW Name:
Last __________________________ First __________________________ Middle _______________ Suffix (e.g., Jr., II)
Address ___________________________________________________________________________________________
City ____________________________ State ______ Zip Code _____________ Telephone ________________________
By signing, I certify that this declaration is made for purposes of my future academic record and that I intend to use this
name consistently at Lakeshore Technical College commencing this date for things such as official transcripts, financial
aid, student identification, and student employment documents. I acknowledge that the College will not modify existing
academic records to reflect this change.
Signature ________________________________________________________________ Date ____________________
Please sign and submit your completed form and required documentation in-person to the Student Services counter, Lakeshore
Building, or submit by mail to address below. This form is not accepted by fax or email.
Address: Student Services
Lakeshore Technical College
1290 North Avenue
Cleveland, WI 53015
Please allow five business days for processing of a name change.
For assistance with this form, submit a question to studentinfo.studentinfo@gotoltc.edu or call 920-693-1109.
Staff Name ___________________________________________________________Date Processed _______________________________
Created: 7/1/15; Revised 12/2/15
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