NAME CHANGE REQUEST FORM FOR CURRENTLY ENROLLED STUDENTS

Please print, complete and return this form along with supporting documentation, as noted below, to the University Registrar’s Office.

OFFICE OF THE UNIVERSITY REGISTRAR

P O Box 5190, Kent State University, Kent, OH 44242-0001

· Students must be currently enrolled in order to change name

· Examples of acceptable certified legal documents include, but are not limited to the following.

Court Order

Marriage License

Birth Certificate

Adoption Order

· Any document submitted by mail must be notarized, with the following statement: This is a certified and true copy of the original document. Name change documentation may not be faxed.

· Note to currently enrolled students who are also employed in some capacity by KSU: In addition you must provide a copy of your social security card for HR requirements.

NAME AS LISTED ON CURRENT RECORDS: (PLEASE PRINT)
_______________________________________________________________________________________
Last	First	Middle or Initial

STUDENT ID Number:__________________________________________

DAYTIME PHONE #: (______)____________-____________________

I hereby request that my academic records be maintained under the name: (PLEASE PRINT)

_______________________________________________________________________________________
Last	First	Middle or Initial

as supported by the legal document (_______________________________________).

_{** Type of Document**}

A certified and true copy of the document accompanies this request.

_____________________________________________________ Signature

__________________        Date