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Request for Change of Name*In order to petition for a change of name you must complete this
form. Supporting
documentation is required. |
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| New Name | ______________________________________________ |
| Former Name | ______________________________________________ |
| Current ID # | ______________________________________________ |
| Anticipated Graduation Date | ______________________________________________ |
| Reason For Name Change ______________________________________________________________
_______________________________________________________________________________________ |
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| Marital Status | ____ Single ____ Married (Used for summary reporting only) |
| Birth Date | ______Month _______ Day _______Year |
How can we reach you if we have questions: |
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| Email Address: | ______________________________________________ |
| Daytime Phone: | ______________________________________________ |
| Student Signature | ______________________________________________ |
| Date | ______________________________________________ |
| supporting documentation | |
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| Fax, mail or bring the completed form to one of the addresses below. | |
| Fax to: 317-278-2240 | ||
| Mail to: | Visit us at : | |
Office of the Registrar |
Office of the Registrar |
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