Registrar’s Office – Clarion University of Pennsylvania 12/2016
Name/Social Security Number Change Form
• Students must type directly on this form or print legibly
• After completion, return form to:
In Person: Clarion Campus By mail or fax: Clarion University
148 Becht Hall Registrar's Office
840 Wood Street
Venango College Clarion, PA 16214
Venango Administration Fax: 814-393-2039
200 Frame Hall
•
Be sure to attach a copy of the appropriate documentation to this form. You may also present original documents in person
and we
will photocopy the original document for our files.
If you have any questions, please contact us at (814) 393-2229 or at registrar@clarion.edu
Clarion ID Number/SSN Daytime Phone
Print CURRENT NAME on file:
Last First Middle
Name Change:
Print NEW AUTHORIZED NAME:
Last First Middle
My name has been changed for the following reason: (check all that apply)
Passport Adoption
Marriage Court Order
Divorce Correction
Effective date of change
A CERTIFIED COPY OF ANY LEGAL DOCUMENT AUTHORIZING A NAME CHANGE MUST ACCOMPANY THIS FORM.
(Examples: marriage certificate, court order, social security card)
Social Security Number Change:
Incorrect social security number:
Correct social security number:
Bring original Social Security card to 148 Becht Hall. We will photocopy the original document for our files.
Form Will Not Be Processed Without Student's Signature.
Student’s Signature Date
Registrar’s Office Use Only
Proof Verified By Date
