Revised 06/2015
Official Name Change Form
NOTE: Form must be typed. Handwritten copies will not be accepted.
This form contains interactive fields allowing for online completion.
Student ID#:
Phone Number:
Email Address:
Former Name:
Last
First
Middle/Maiden
Please print the name you wish to appear as your official name on record:
Last
First
Middle/Maiden
Two (2) forms of documentation from the following list are required for processing:
M
arriage License
Court Order
Divorce Decree
Birth Certificate
Social Security Card
Adoption Documentation
Annulment Documents
Driver’s License
Passport
M
ilitary ID
If you have applied for graduation and would like to change your diploma or certificate to reflect
this name change, please check the appropriate box: Yes No
Student Signature
Date
Are you currently enrolled?
If no, last semester at USM:
Complete and return to The University of Southern Mississippi Registrar's Office
118 College Drive Box 5006 Hattiesburg, MS 39406
Phone: (601) 266-5006 Fax: (601) 266-5816
Email: registrar@usm.edu
Yes
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