·
Student ID number Social Security Number
First Middle/Maiden
Student’s Signature (required)
Date
·
Student ID number Social Security Number
First
Middle/Maiden
First
Middle/Maiden
Last
Student’s Signature (required)
Date
Last
Telephone Number
Last
Last
First
Middle/Maiden
Telephone Number
Change Name From
Change Name To
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Louisiana Delta Community College
Division of Student Affairs Office of Enrollment Services
Change of Name Form
To change your name for any reason (e.g., divorce, marriage, adoption, legal name change), you must;
• Complete and Sign this for m;
• Present your original social secur ity car d; and
• Provide a photo ID.
Presenting a copy of your card is not acceptable, and no other document or form of identification will be accepted in lieu of the Social Security Card. Only the name as it appears
Will you graduate from Delta during the current term: Yes No
By my signature below, I verify that the statements above are correct.
For Oce Use Only:
Processed By:
Date:
Louisiana Delta Community College
Division of Student Affairs Office of Enrollment Services
Change of Name Form
To change your name for any reason (e.g., divorce, marriage, adoption, legal name change), you must;
• Complete and Sign this for m;
• Present your or iginal social secur ity car d; and
• Provide a photo ID.
Presenting a copy of your card is not acceptable, and no other document or form of identification will be accepted in lieu of the Social Security Card. Only the name as it appears
on the Social Security Card will become part of the student’s Delta record. The name on the Delta record will reflect the name exactly as it appears on the Social Security Card.
Change Name
From
Change Name To
Will you graduate from Delta during the current term: Yes No
For Oce Use Only:
Processed By:
Date:
