N
OTE: If you are an employee of the University, you must also contact Human Resources to update your name/address.
NAME CHANGE (COPY OF DRIVERS LICENSE or GOVERNMENT ISSUED PHOTO ID REQUIRED)
*If you wish to have your name changed on your U of M Email account please contact ITS Help Desk
New Name: ____________________________________________________________________________________________
Last First Middle Name or Initial
Previous Name: _________________________________________________________________________________________
Last First Middle Name or Initial
Will you need your name changed on your diploma? Yes No
Local Mailing Address: (COPY OF DRIVERS LICENSE or GOVERNMENT ISSUED PHOTO ID REQUIRED)
Valid from: ________/ ________/ ________ Until This Date: ________/ ________/ ________
Address: __________________________________________________________________________
City/State/Zip: _____________________________________________________________________
Primary Phone Number for This Address: ________________________________________________
Permanent Address:
Address: __________________________________________________________________________
City/State/Zip/Country: ______________________________________________________________
Home Phone: ___________________________ Mobile Phone: ______________________________
*Home Email Address: _____________________________@_________________________________
*please note the University does all correspondence through the University Email Account
SOCIAL SECURITY NUMBER CHANGE /CORRECTION (COPY OF SIGNED SOCIAL SECURITY CARD REQUIRED)
Former Social Security Number New/Correct Social Security Number
________/________/________ ________/ ________/ ________
DATE OF BIRTH CORRECTION (COPY OF DRIVERS LICENSE or GOVERNMENT ISSUED ID REQUIRED)
Former Date of Birth New/Correct Date of Birth
________/ ________/ _______ ________/ ________/ ________
University of Michigan – Flint
266 University Pavilion, 303 E. Kearsley
Street, Flint, MI 48502
Phone: (810) 762-3344 Fax: (810) 762-3346
Name: _______________________________________ Student UMID: ______________________________
Preferred First Name: ______________________________ Remove Preferred Name
To be displayed on class rosters & unofficial documents
D
ate of Birth: ________________________________ Telephone: ___________________________________
Signature _____________________________________ Date: ________/ ________/ ________
