The College at Brockport
State University of New York
NAME CHANGE FORM
Office of Registration and Records
350 New Campus Drive, Rakov 201
Brockport, NY 14420-2966
Phone: (585) 395-2531
Fax: (585) 395-5392
Email: registrar@brockport.edu
NAME CHANGE/CORRECTION
Please attach two forms of appropriate documentation; one form of documentation must be either a
marriage certificate or a court order, the second form, a photo ID.
Completed forms, with photocopies of documents, can be mailed, emailed, faxed, or walked in.
Banner ID ___________________________________________
Enter your name as it currently appears on the college records:
Last First Middle
Complete new name:
Last First Middle
Signature Date