Request for Change of Name

Student Identification Number   

Date of Birth   January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Currently Enrolled   Yes No

College of Last Enrollment   Student Academic Services Center Arts & Sciences Business Education Health & Human Performance Nursing Technology Graduate

 Previous Name

Last                                  First                               Middle

New Name

Last                                  First                               Middle

Reason For Change   Marriage Divorce Other 

You will be required to supply supporting documentation; i.e., certified copy of marriage license, divorce decree, etc.

I certify the above is true and correct __________________________        _________________

                                                          Student Signature                                        Date

Telephone and address where you may be reached :

( )

Please print and return completed form to Office of Registration and Records
Parsons Hall, Room 009
Indiana State University, Terre Haute, IN 47809