Update Contact Information
Change of Name, Address, Email, or Phone Number
University of North Texas Health Science Center
Office of the Registrar, SSC 240
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2699
(817) 735-2201 / Fax (817) 735-0448
Questions regarding data collected may be directed to the Registrar. (HB 1922)
Student ID OR Social Security Number
Date of Birth
Texas College of Osteopathic Medicine
Graduate School of Biomedical Sciences
School of Public Health
School of Health Professions (PA & DPT)
System College of Pharmacy
Last Name First Name Middle Name
Email Address
Other Names Used While Enrolled at UNTHSC
Graduating Year
Update Contact Information
Change my mailing address to:
Change my permanent address to:
Update my phone number to:
Primary: ______________________
Mobile: _______________________
Other: ________________________
Update my personal email address to:
Change of Name
To make an official name change, the student must provide identification and legal documentation of the change. An example might include a
marriage license or divorce decree. Registrar’s Office personnel must make a copy of the original documentation before completing the change.
Previous Name: ________________________________________________________
New Name:
First Name
Middle Name
Last Name
Attached is a copy of my identification.
(Example: driver’s license, passport, etc.)
Attached is a copy of the legal documentation of the name change.
(Example: marriage license, divorce decree, court order, etc.)
I certify that I am the person whose name appears on the name line of this form,
and do hereby authorize the change of my student record information.
_______________________________________________ ____________________
Signature Date
Please allow 24-48 hours for processing.
For Office Use Only
Revised 03/13/2017 EIS Updated__________
click to sign
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