NAME CHANGE FORM
June 2015
CURRENT PERSONAL INFORMATION
Employee ID Student ID
Date of Request
First Name
Last Name Middle
Preferred First Name
Prefix
Suffix
UML Email Address
@uml.edu
NEW PERSONAL INFORMATION
First Name
Last Name Middle
Preferred First Name
Prefix
Suffix
Employee Signature
Date
This form should only be used if you have legally changed your name. If your name has changed, you
must present in person an original version of one of the acceptable documents listed below, along with
this completed form to:
University of Massachusetts Lowell
Human Resources and Equal Opportunity & Outreach
Wannalancit Mills
600 Suffolk Street, Suite 301
Lowell MA 01854
By submitting this form your name will update in HR Direct, SiS, GIC benefits, email and directory.
LIST OF ACCEPTABLE DOCUMENTS (check one)
Social Security Card
Legal Name Change Document
NOTE: Be sure to update your name with the Social Security Administration.
HR/EEO USE ONLY
Update:
HR Direct ____ I-9 ____ Benefits ____ File_____
Send to:
Registrar ____ IT ____
Completed by ___________________________ Date ___________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome