Office of Admissions and Student Records
Revised 10/2014 Address: 601 E. College Drive, P.O. Box 270 Winnebago, Nebraska 68071 Phone: 402.878.3307 Fax: 402.878.2309 Website:
Name Change Form
In order to have our name changed on your permanent record at Little Priest Tribal College, you must present a
copy of one of the documents listed below. Please check the supporting document you are providing:
___ Driver’s License (in new name) ___ Social Security Card (in new name)
___ Marriage license ___ Court Decree ___ Divorce Decree
Present Name on Record:
Last First Middle Former
Social Security Number: ____________________________________
Change Name to:
Last First Middle Former
I hereby authorize that my name be changed, as indicated above, on all current and subsequent entries to my
permanent records at Little Priest Tribal College. I certify that the above change has been authorized through
appropriate legal action and have attached the supporting legal documentation of this name change.
__________________________________________________ ____________________________
Student’s Signature Date