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Registrar’s Office
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
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
