□
Passport
□ Driver’s License
□ Name Change Certificate/Notarized letter
□ Marriage Certificate
□ Divorce papers/Divorce order/Certificate of divorce/Decree Nisi/Annulment Certificate
Name requested to appear for purposes of
Degree Diploma: _____________________________________________________
□ Alteration to spelling of name(s)
□ Removal of middle name
□ Complete name change
Please return completed form to: Student Central
Western Student Services Building, Room 1120, London, ON, N6A3K7, Canada Tel: (519)661-2100 Fax: (519)850-2590 Email: contact@uwo.ca
NAME CHANGE REQUEST FORM
Name (as it appears now on Student Center)
Option 1: Requests to Change Students’ Legal Names on Academic Records
Students who wish to change their name used for official registration purposes. The name will appear on all official academic
records and diplomas.
Name Change Types (select one ☑)
□
Change to Surname
□ Change to Given Name
□ Addition of middle name
I.D Required Must present TWO pieces of acceptable documentation, one of which must be photo ID
that confirms the change you are
requesting (e.g. changing your name from Smith to Jones would require ID reflecting “Jones”).
Identification (Select two ☑)
Option 2: Request for Variation of Students’ Name on Degree Diplomas
Students who wish to include a variation of their complete name for the purpose of their printed degree ONLY are required to
complete the information below. The name variation for the printed degree will be retained as part of the student's permanent
record and displayed separately on official transcripts with the degree conferral information.
ONLY Change Types Permitted (no documentation required) **Please note: Addition of middle name is not a permitted type
Student
Signature
: Date: ___
The personal information on this form is collected under the authority of the University of Western Ontario Act, 1982, as amended. To view a
complete Personal Information Collection Notice visit the online Academic Calendar at: http://www.westerncalendar.uwo.ca
New Legal Name
(as reflected in appropriate documentation provided)
________________ , _______________ , ______________
Last First Middle
□
Using both capital and lower case letters (
MCKENZIE
to McKenzie)
□ Diminutives of names JAMES to JIM
□ Variation in the order of names, Surname/Given name
□ Addition of accent, NOELLE to NOËLLE
□
Removal of middle names (e.g. JANE ANN SMITH to
JANE SMITH)
□ Use of religious names (e.g. addition of the name MOHAMMAD)
□ Truncation of First or Middle names (e.g. Alexander to A.)
□ Use of previously approved Preferred/Chosen first name
□
Government-issued photo identification e.g. Citizenship Card
□ Joint declaration of conjugal relationship
□ Death Certificate of spouse
□
Other
Please note: Requests to include accents will NOT be included on official transcripts or displayed as part of the student’s
centrally
maintained academic record.
click to sign
signature
click to edit
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