!
!
!
!!1101!Sherman!Drive,!Utica,!NY!13501!
!!!!!!!!!!!!!!!!Phone!(315)!792=5336!
!!!!!!!!!!!!!!!!!!Fax!(315)!792=5698!
!!!!!!!!!!!!!!!!!!!!!!www.mvcc.edu!
!
Two ID’s are required (at lease ONE PHOTO ID):
Driver’s License
Divorce / Marriage Certificate
Court Action
Social Security Card
Passport (required for non-US citizens)
If you are currently an employee at Mohawk Valley Community College, please process your name
change through the Human Resources Office, Academic Building, Room 113, Utica. If you have any
questions contact the H.R. Office.
If your ONLY status is STUDENT, complete this form and submit to the Officeof Records and Registration,
Payne Hall, Room 118, Utica, or Plumley Center, Room 117, Rome.
Are you currently a STUDENT at Mohawk Valley Community College?
Are you a Degree / Certificate Candidate?
Previous Last Name (On MVCC Records) _____________________
Previous First Name _____________________ Primary Phone Number _____________________
Student M# _____________________ Social Security Number _____________________
NEW Last Name (Family Name) ______________________________________________________
NEW First Name, Middle Initial ______________________________________________________
Requires at least TWO VALID and ORIGINAL forms of Identification. Both forms of the required
identification must show the NEW name.
OFFICE USE ONLY
!
Rec eived!By/Dat e! ____________________!
Posted!By/Date!____________________!
CHANGE OF
(LEGAL) NAME
REQUEST
!
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome