LEGAL NAME CHANGE FORM
Submit to:
Registrar’s Ofce
Clarke University
1550 Clarke Drive
Dubuque, IA 52001
registrar@clarke.edu
Identification (Use Legal Name)
Full Name: First ___________________ Middle ___________________ Last ___________________
A copy of your social security card is required for verification of a legal name change (Attach a copy):
Previous Name: First __________________ Middle __________________ Last __________________
Gender: __________________
Date of Birth: __________________ Email Address: _________________________
Student Signature: __________________________________ Date: __________________
_____________________________________________________________________________
Registrar’s Office Use Only:
Received: ____________ Processed By: ____________ Date: ____________ Student ID: ___________
click to sign
signature
click to edit
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