Office of Records & Registration
Payne Hall, Room 159A
1101 Sherman Drive Utica, NY 13501
Phone: 315.792.5336
Fax: 315.792.5698
Email: Registrar@mvcc.edu
Plumley Complex, Room 117
1101 Floyd Avenue
Rome, NY 13440
Phone: 315.334.7708
Fax: 315.334.7726
11/15/2016
PREFERRED NAME REQUEST
To request a preferred name, bring this form and your college ID to the Office of Records & Registration at Payne
Hall 159A on the Utica campus or Room 117 of the Plumley complex on the Rome campus.
Your preferred name will not be printed on any official document requiring your legal name such as transcript,
Diploma, Financial Record, and enrollment verification without a legal change of name form processed. The
preferred name will be used in place of your legal name in accordance with our policy. Please review the policy on
our website for specifics. This form needs to be completed by the following dates: 12/10 for spring semester; 5/10
for summer semester; 8/10 for fall semester.
LEGAL NAME:
M____________________________
College ID
Last Name
First
MI
Local Address: Street Apt. No. MVCC
E-mail
( )
City State
Zip Code
Telephone Number
PREFERRED NAME:
Date of Birth
First Name
I have read the information above and understand the uses of the preferred name and the Legal name.
Signature (
REQUIRED
)
Date
MVCC recognizes that many students, faculty, and staff prefer to use first names other than their legal ones to identify
themselves. As long as the use of this preferred name is not for the purpose of misrepresentation, the college
acknowledges that
a “preferred name” can and should be used where possible in the course of college business and
education.
Disclaimer:
This policy does not form a contract of any kind and may be modified, changed, altered, or rescinded at the discretion of
MVCC. Inappropriate use of the preferred name, including but not limited to misrepresentation or attempting to avoid
a legal
obligation, may be cause for denying the request.
ta
MVC
-C
I
MOHAWK
V.
AUEY
'
COMMUNITY
CO
ILL
EG
IE
click to sign
signature
click to edit
![]()
