Name Change Request
Records Office - Middle Tennessee State University - Murfreesboro

It is requested that my name on my records at MTSU be changed as follows:

*If you have filed an Intent to Graduate form and wish to change your name on your diploma, you must call 898-5170 or come to the Records Office, Cope 102, and state specifically that you want to change the name on your diploma.


Present name    
 
(last)    
(first)
(middle)

Social Security Number:  - -     Are you currently enrolled?  Yes No

 
Former name    
 
(last)    
(first)
(middle)

Note any other names under which your record might be filed 

I certify that I intend to use this name consistently and I am not changing my name for fraudulent purposes.

             ____________________________________
Date                                                        Signature

FOR OFFICE USE ONLY:

Computer file _____________________________  Cross-reference cards _________________

Permanent record __________________________  Folder _____________________________

AR020-0302

 

PRINT THIS FORM AND MAIL OR FAX OR RETURN TO COPE 106

Records Office, Middle Tennessee State University, Murfreesboro, TN  37132 
Fax: 615-898-5538, Office:  Cope Administration Building 106.