___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Registrar’s Office
Petition for Legal Name Change
Please complete this form, unsigned, and return in person with legal documentation (no faxes or copies of legal documents will be accepted) to Registrar’s Office, SSC L157.
Directions: Complete petition and attach legal documentation. Institutions may accept federally-recognized identifications (i.e. passports), state verified driver licenses, court
orders arising from a name change proceeding, an adoption, a divorce degree, individual choice or witness protection program, and marriage licenses as documentation of
identity for legal name change process.An unverified state driver license, also referred to as a “Drive Only License,” may not be used for this purpose since its issuance relates to
the ability to operate a vehicle. It does not establish a legal identity.This petition will change all records maintained by the Registrar, including subsequent credentials conferred
by the institution. Include hyphens, apostrophes, commas, periods and spaces. Other special symbols cannot be entered onto your records. Sign the petition after presentation to
personnel in the Registrar’s office with photo ID.
STUDENT PERSONAL INFORMATION
Student ID Number Date of Birth
Please indicate current name used on college records.
Current First Name Current MI Current Last Name
Please indicate new legal name to be used on college records.
New First Name New MI New Last Name
Current Mailing Address Apt. #
City State Zip
Phone Number Email
REQUIRED
I affirm that I am the above named person and that the information presented is true.
Student Signature Date
OFFICE USE ONLY
Received and Verified By: _____________________________________ Date Received: _____________________________________________
Type of Documentation: _______________________________________ Date Entered: ______________________________________________
Student Folder/Records Change: __________________________________ Notations: _________________________________________________
Student Notified of Change: ____________________________________ Internal Notifications: _________________________________________
Comments: ___________________________________________________________________________________________________________
November 2018/PR
