NAME CHANGE FORM
I. Student Information
1.
Student ID #:
2.
Program:
❒ Bachelor of Arts in Liberal Arts ❒ Master of Arts in Buddhist Classics
❒ Graduate Certificate in Buddhist Translation
II. Name Information
1.
New Legal Name:
First Name
Middle Name
Last Name
2.
Prior Name:
First Name
Middle Name
Last Name
3.
Preferred Name:
Reason for Change:
Please provide a copy of the approved documentation reflecting the new name:
❒
Marriage
❒ Marriage Certificate and
❒ Government-issued photo ID
❒
Legal Change
❒ Court Order and
❒ Government-issued photo ID
❒
Divorce
❒ Divorce Decree and
❒ Government-issued photo ID
❒
Adoption
❒ Court Order and
❒ Government-issued photo ID
❒
Spelling Error
❒ Government-issued photo ID
❒
Gender Change
❒ Court Order and
❒ Government-issued photo ID
❒
Other (please specify)
I certify that I am the above-named person and the information I have provided is accurate.
Date:
Student's Signature:
For Registrar/Records Office Use Only:
Date: ___________________ Received by: _____________________________________
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