Name Change

Graduate Liberal Studies Program
284 High Street
Middletown, CT  06457
Phone (860) 685-2900
Fax (860) 685-2901
   
 
Student Information
___ ___ ___ ___ ___ ___  
WesID# Current name: first, middle, last    
       
Home address City State ZIP
       
Home phone Work phone Preferred e-mail  
Request:  Change of Name
Former first name:

Former middle name:

Former last name:

  

attests that on (date)

    his/her name was changed to:

New first name:

New middle name:

New last name:

  

 

 and that this is the name that he/she is now and will hereafter be known.

 		  

Student's signature

Date  

County of:

State of:
Notarization of name change

Subscribed and sworn to before me this date: _________________________

 
Notary's signature

Official Notary Seal:

 
Change of name Policy

To implement a student's official, legal change of name, Wesleyan University's Graduate Liberal Studies Program requires that the student submit proof of name change.  The student shall complete this form and present it to a Notary Public with appropriate legal documentation (marriage certificate, divorce decree, etc.).  The student shall then submit to the Graduate Liberal Studies Program office this original notarized form which includes the raised Notary Seal, as proof of the change of name.  Only upon receiving this complete original notarized form will the Graduate Liberal Studies Program record a student's change of name.

Office Use Only
Date received: Approved by: Approval Date: Term:
       
Recorded by: Date recorded: