Request for Usage of a Preferred
First Name or Used Name
Directions: Complete this form, unsigned, and return in person with photo ID to Registrar’s Ofﬁce, SSC L157. All reasonable requests will be granted.This form will change the
applicant’s ﬁrst name on all institutional documents and records other than ofﬁcial documents such as credentials and transcripts. Documents and records that may display a
preferred or used name include, among others, course rosters, identiﬁcation cards, email addresses, and honors, awards and prizes issued by the institution. Include hyphens,
apostrophes, commas, periods and spaces. Other special symbols cannot be entered onto your records. Sign the form after presentation to personnel in the Registrar’s ofﬁce.
STUDENT PERSONAL INFORMATION
Student ID Number Date of Birth
Please indicate legal name as it appears now on college records.
Legal First Name Legal MI Legal Last Name
Please indicate preferred ﬁrst name or used name.
First Name MI Last Name
Current Mailing Address Apt. #
City State Zip
Phone Number Email
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: _________________________________________