PERSONAL INFORMATION CHANGE ON OFFICIAL UNIVERSITY RECORD
Use this form to request East Tennessee State University to change your name, mailing address, phone number, or marital status
on official records. Only complete the sections necessary for your desired change. Required documents and processing
instructions vary depending on your relationship to the University. Complete the form, attach required documents, and
submit according to the instructions below. You may submit all documents in person, by mail, or by completing the online form.
Submit your completed form and supporting materials to one office onlythe office in the first relationship you check below.
If you are
Submit form and documents to
Employee (Faculty / Administrator / Staff)
Complete the online "Employee Personal Information Change Form" located on the ETSU Human
Resources
Documents and Forms page
or return this form to the Office of Human Resources
307 Burgin Dossett Hall Box 70564 Johnson City, TN 37614
Phone: (423) 439-4457 or 7089
Student Employee (Federal Work
Study/Regular Student Work Program)
Office of Financial Aid 105 Burgin Dossett Hall Box 70722 Johnson City, TN 37614
Fax: (423) 439-5855
Medical Resident
Graduate Medical Education College of Medicine Suite C-216 Stanton-Gerber Hall Box 70415
Johnson City, TN 37614
Fax: (423) 439-8910
Student Submit form and supporting
documents to the office as it pertains to
you (e.g., medical students to the college
of medicine; pharmacy students to the
college of pharmacy; and all other students
to the Registrar)
Office of the Registrar 102-A Burgin Dossett Hall Box 70561 Johnson City, TN 37614
Fax: (423) 439-6604
College of Medicine Suite C-240 Stanton-Gerber Hall Box 70580 Johnson City, TN 37614
Fax: (423) 439-2110
College of Pharmacy Room 216, VA Bldg. 7 Box 70414 Johnson City, TN 37614
Alumnus/Alumnae individuals who have
not been enrolled in classes at ETSU for
one or more semesters
Advancement Office Yoakley Hall 3rd Floor Box 70721 Johnson City, TN 37614
Fax: (423) 439-5836
Other (Use only if no other category
applies - e.g., donor, or business)
Advancement Office Yoakley Hall 3rd Floor Box 70721 Johnson City, TN 37614
Fax: (423) 439-5836
Required Documentation for Each Change
Legal Name
Completed form, updated Social Security card AND a related document such as marriage certificate, divorce decree, or court order.
Preferred Name
If you wish to change your preferred name, use the
Preferred Display Name Change Request Form
.
Mailing Address
Completed form and proof of new address such as photo ID, new lease, utility bill, etc.
Phone Number Completed form.
Marital Status
Completed form, marriage certificate/divorce decree and Social Security card reflecting new name (if applicable).
Please note that those under the Alumnus/Alumnae and Other category ONLY have to submit a completed form to change their information.
For employees, remember to update your beneficiaries and W-4 Form. For beneficiary information, visit Employee Benefits FAQ. If you changed your legal name, mailing address, or
need to update your tax withholdings, you must submit a new W-4 Form in person to the Payroll Office at Burgin Dossett Hall Room 311. A photo ID will be required.
Your information as it is currently listed on your ETSU Record:
Your new information supported by documentation:
First Name
First Name
Middle Name
Middle Name
Last Name
Last Name
Your information as it is currently listed on your ETSU Record:
Your new information supported by documentation:
Suffix
Suffix
Street Address
Street Address
Address Line 2
Address Line 2
City
City
State
State
Zip Code
Zip Code
Phone Number
Phone Number
Marital Status
Marital Status
E Number
Check all relationship categories that apply:
Current employee with benefits
Former employee last date worked ________________month/year
Current student
Former student/not graduated Last Term Attended _____________
Current employee without benefits
GA/Student Worker
F1/J1 Visa (Passport or Marriage Certificate)
Reason for Name Change (if marital status change, please indicate
new status)
Do you want to change your
computer user name?
yes no
If yes, complete the Computer Account Name Change Request form on
the ITS Forms website.
Financial Aid applicants/
recipients
I understand that I cannot change my legal name as it appears on my birth certificate and/or with the Social
Security Administration without supporting legal documents. If I do not have the necessary legal documents, I
forfeit my rights to any current or future financial aid disbursement. I understand that my name on my official
university record and my legal name must match in order for me to receive financial aid.
By signing below, I assume responsibility for notifying my instructors, supervisors, and all other relevant parties of my name change
and accept ownership of any consequences or problems that may occur as a result of this name change or modification of my
personal information. It is not my intent to defraud East Tennessee State University.
Signature
Date
Office Processing Change: ______________________________ By: __________________________________________ Phone: ________________ Date:___________________
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