Records Office
1665 Hampshire Pike
Columbia, TN 38401
(931) 540-2581
(931) 560-4112 (fax)
1. Please print your name and social security number as it is currently listed on your academic records:
Name: ____________________________________________________________ Social Security # __________________________________
2. NAME CHANGE (Print your new name as you wish it to appear on your records.)
________________________________________/___________________________________/___________________________________
Last Name First Name Middle/Maiden
3. If you have filed for graduation and want your new name on your diploma check here ______
4. SOCIAL SECURITY CHANGE Old Social Security #: ______________________ New Social Security #: _____________________
5. DATE OF BIRTH CHANGE MY CORRECT BIRTHDAY IS _____________
6. What is your current phone number? (_____)_____________
7. What is your personal email address? _______________________________________
___________________________________________________________________ ___________
Signature Form will not be processed without signature or without proper documentation Date
REQUEST FOR CHANGE OF NAME, SOCIAL SECURITY, and/or DATE OF BIRTH
TO AVOID GRADING ERRORS, THE STUDENT MUST NOTIFY EACH INSTRUCTOR OF THESE CHANGES!
Copy of driver’s license, marriage certificate, or social security card is REQUIRED for name changes.
Copy of social security card is REQUIRED for social security changes (copy of driver’s license is
acceptable if SS# appears on license).
Copy of driver’s license or birth certificate is REQUIRED for date of birth changes.
Submit completed and signed form with required documentation to the Records Office.
records@columbiastate.edu
