Fillable Minnesota State University Student Name Change Request Form

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Minnesota State University Student Name Change Request Form

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The Minnesota State University Student Name Change Request Form form is 1 page long and contains:

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Country of origin: US
File type: PDF

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_______________________________________________________________________________________________________________________________________
To change your official name on your student academic record, please complete this form and return to the MSUM
Registrar’s Office. You must include a photocopy of your social security card that shows your NEW legal name. The new
name you list on this form must exactly match your name as it appears on your new social security card.
Af
ter the name change is processed, you have the option to update your university email address and Dragon ID card.
• To update university email address contact support@mnstate.edu
, go to Library 203, or call 218-477-2603.
• To update Dragon ID card go to Library 122 or call 218-477-2603.
Previous Name (name currently listed in our student record system)
Legal Name (Last, First, Middle) Star or Dragon ID
Date of Birth (mm/dd/yyyy) Phone Number Email Address
New Name (as it appears on your new Social Security card)
Legal Name (Last, First, Middle)
My signature below certifies that I am requesting my name be changed on my Minnesota State University Moorhead
records, and that the information I have provided on this form is true and accurate to the best of my knowledge.
Signature: ______________________________________________________________Date: ______________________
Return form to:
Minnesota State University Moorhead
Registrar’s Office | Owens Hall 210
1104 7
th
Ave S
Moorhead MN 56563
Phone: 218.477.2565
Fax: 218.477.2941
Email: Registrar@mnstate.edu
Minnesota State University is an equal opportunity educator & employer and is a member of the Minnesota State System.
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Minnesota State University Student Name Change Request Form

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Completed 14 April 2020

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