Directions: Complete form and attach legal documentation, which includes federally-recognized
identifications (i.e. passports), state verified driver licenses, court orders arising from a name change
proceeding, an adoption, a divorce degree, individual choice or witness protection program; and
marriage licenses as documentation of identity for legal name change process. An unverified state
driver license, also referred to as a “Drive Only License,” may not be used for this purpose since its
issuance relates to the ability to operate a vehicle. It does not establish a legal identity. This petition
will change all records maintained by the Office of the Registrar, including subsequent credentials
conferred by the institution. Include hyphens, apostrophes, commas, periods, and spaces. Other
special symbols cannot be entered onto your records. Sign the form after presentation to
Registrar’s Office personnel with photo ID.
Personal Information:
Student ID Number @________________________ Date of Birth: ______________________
Current Name on College records _____________________________________________________
(First Name) (Middle Name) (Last Name)
New Name ________________________________________________ _______________________
(First Name) (Middle Name) (Last Name)
Current Address: ___________________________________________________________________
City/State/Zip Code
Phone________________________ Email Address________________________________________
I affirm that I am the above named person and that the information presented is true.
Student Signature ___________________________________________ Date __________________
Office Use Only
Received and Verified by _________________________ Date Received ________________________
Type of Documentation ____________________________ Date Entered__________________________
Student Folder/Records Changed ___________
Green Woods Hall Room 215
Park Place East, Winsted, CT 06098
(860) 738-6314
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