Rev: 09/17
Office of the Registrar
Name Change Request Form
Liberty Student ID: ___________________________ Date of Birth (mm/dd/yy):____/____/____
Previous Name: ________________________________________________________________
New Legal Name: ______________________________________________________________
Email: _____________________________________ Phone Number: (_____) _____-________
Are you currently enrolled? Yes No: Last Date Attended:________________________
This request form must be accompanied by an updated Social Security Card AND one of the
below legal documents verifying your new name.
Additional Legal Documentation Attached: Update Address:
Marriage Certificate Address:___________________________
Divorce Decree ___________________________
Legal Name Change Certificate ___________________________
Newly Issued Passport Permanent
Newly Issued Driver’s License Mailing
Student’s Signature:_________________________________________ Date:_____________
Student Information
Special Instructions and Information
Student Authorization
Registrar’s Use Only Processed By:______________________ Date:_______________
(First) (Middle) (Last)
(First) (Middle) (Last)
Please be aware that your new name will be sent to all faculty and staff in a roster update after your record is formally updated.
*Contact Information & Instructions
Submit Request(s) to:
College of Osteopathic Medicine
Registrar’s Office
306 Liberty View Lane, Lynchburg, VA 24502
Tel. (434) 592-5200 · Fax (434)582-3902 ·
*Allow 3-5 business days for processing.
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