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
Mailing Parent Address (Indicate address type)
Address (Street Name and Number) Apt#
City State Zip/Country
Area Telephone Number
*REQUIRED. THIS FORM CAN NOT BE PROCESSED IF NOT SIGNED AND DATED.
FOR OFFICE USE ONLY:
Type of I.D.:
Other (specify) ________
EXAMPLES OF APPROVAL FORMS OF IDENTIFICATION:
Human Resources Office:
Social Security Card (required for name change
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.