NAME/ADDRESS CHANGE REQUEST FORM
University of Central Arkansas
PRINT OR TYPE ALL INFORMATION- Incomplete forms cannot be processed
ID# B_____________ NAME: ______________________________ Student Staff/Faculty
SSN#____________________ (For UCA Employees only) EMAIL________________________________________
Change Name To:
Last Name Suffix First Name Middle Name
Change Address:
Mailing Parent Address (Indicate address type)
Address (Street Name and Number) Apt#
City State Zip/Country
______________________________________________
Area Telephone Number
_________________________________________________________
*Signature *Date
*REQUIRED. THIS FORM CAN NOT BE PROCESSED IF NOT SIGNED AND DATED.
FOR OFFICE USE ONLY:
Type of I.D.:
Driver’s license
Marriage license
Birth Certificate
SSN Card
Court order
Other (specify) ________
By:_________________
Recorded:
Computer record
Paper record
Date:_______________
EXAMPLES OF APPROVAL FORMS OF IDENTIFICATION:
Registrar’s Office:
Driver’s License
Marriage License
Birth Certificate
Court Order
Human Resources Office:
Social Security Card (required for name change
only)
Note: To change your name/address on personnel records, please complete this form and return it to the Human
Resources Office with an acceptable form of identification showing the applicable changes.
To change your name/address on the permanent student record, please complete this form and return it to the Office
of the Registrar with an acceptable form of identification showing the applicable changes.
For CURRENT UCA EMPLOYEES ONLY, check one of the following:
__ Full-Time __Part-Time __Temp __Graduate Assistant __Student Assistant
I request UCA include my most
recent former last name on any
transcript that is released.
Yes___ No___
